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COPYRIGHT DKPOSrr. 



ESSENTIALS OF 
OPERATIVE DENTISTRY 



ESSENTIALS OF 



OPEEATIVE DENTISTEY 



BY 

W. CLYDE DAVIS, M.D., D.D.S. 

DEAN AND PROFESSOR OF OPERATIVE DENTISTRY AND TECHNIC, LINCOLN DENTAL 
COLLEGE, LINCOLN, NEBRASKA. 



SECOND REVISED EDITION 




ST. LOUIS 

C. V. MOSBY COMPANY 

1916 



-^"^ 






\t 



Copyright, 1916, by C. V. Mosby Compan-y 



AUG 1 7 1916 



Press of 

C. V. Mosby Comfany 

St. Louis 



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^ 



PEEFACE TO SECOND EDITION. 

In presenting the second edition of this Avork, it is the aim 
of the author to follow the plan of the first edition, in that it be 
concise and yet cover a Avide field in operative dentistry. 

The book has been thoroughly rewritten and extensivel}^ illus- 
trated. Four new chapters have been added, several have been 
materially enlarged, and others eliminated entirely in this edition. 

There is a complete rearrangement of the chapters which it is 
believed will more nearly coincide with the progress of the stu- 
dent through his technical work and the operatory. 

W. C. D. 



PKEFACE TO FIRST EDITION, 

In the preparation of this text-book it has been the author's 
aim to meet a demand in dental college work for a treatise on 
operative dentistry which is sufficiently condensed to enable the 
student to master its contents in the comparatively short college 
terms at his disposal. 

The subject matter selected is that which is generally taught 
by the instructors styled as ''Professor of Operative Dentistry." 

From a study of these teachers' courses of instruction it would 
seem that the definition of Operative Dentistry as commonly used 
today would be ''That branch of dentistrj^ which treats of the 
mechanical procedures performed within the oral cavity looking 
to the salvage of the teeth." 

However, it has seemed wise in several instances to go beyond 
the exact limitations of this definition to get a better correlation 
of subjects. 

The arrangement of the subject matter is different from that 
usually found, but is in accordance with the usual line of progress 
of dental students. 

The author claims little originality in the essentials presented, 
having gleaned the facts from the writings, teachings and utter- 
ances of our greatest educators. 

The "quiz-explanation" method of teaching is the one most in 
vogue in the leading universities as productive of the most work 
on the part of the classes taught, and at the same time giving 
the tutor more freedom for the expression of opinions to give 
individuality to his course of instruction. 

An effort has been made to so publish the "Essentials of Oper- 
ative Dentistry" that it would serve as a foundation for this quiz 
course as well as be suggestive to the teacher for a more full 
explanation, and, at the same time, encourage the student to ex- 
tend his studies to more voluminous reference books, when time 
would permit, for an explanation in greater detail. 

The author is much indebted to his co-laborer, partner and wife, 
Mattie M. Davis, D.M.D., for valuable assistance in connection 
with the publication of this volume. 

W. C. D. 



CONTENTS 

PART I. 

CPIAPTER I. Page 

Instrument Nomenclature 17 

CHAPTER II. 
Cavity Nomenclature 21 

CHAPTER III. 
Cavity Preparation. (General Considerations.) 29 

CHAPTER IV. 
Gaining Access 31 

CHAPTER V. 
Outline Form 34 

CHAPTER VI. 
Resistance Form 38 

CHAPTER VII. 
Retention Form 40 

CHAPTER VIII. 
Convenience Form 42 

CHAPTER IX. 
Removal of Remaining Carious Dentine. — Finishing Enamel Walls. — 

Toilet of the Cavity 44 

CHAPTER X. 
Management of Pit and Fissure Cavities. (Class One.) 48 

CHAPTER XI. 
Management of Pit and Fissure Cavities. (Class One, Concluded.) . . 52 

CHAPTER XII. 

Management of Proximal Cavities in Bicuspids and Molars. (Class 

Two.) 58 

CHAPTER XIII. 
Large Proximal Cavities Endangering the Pulp. (Class Two, Con- 
tinued.) 65 

9 



10 CONTENTS 

CHAPTER XIV. Page 

Management of Proximal Cavities in Incisors and Cuspids Not Involv- 
ing the Angle. (Class Three.) 72 

CHAPTER XV. 

Management of Proximal Cavities in Incisors Involving the Angle. 

(Class Four.) 78 

CHAPTER XVI. 
Management of Cavities in the Gingival Third. (Class Five.) .... 93 

CHAPTER XVII. 

Management of Abraded Surfaces. Occlusal and Incisal. (Class Six.) 96 

CHAPTER XVIII. 
Cavity Preparation for Gold Inlays 98 



PAKT IT. 

CHAPTER XIX. 

The Making and Setting of a Gold Inlay 112 

CHAPTER XX. 

Manipulation of Cohesive Gold in the Making of a Filling 123 

CHAPTER XXI. 

Manipulation of Cohesive Gold in the Making of Fillings by Classes . 129 

CHAPTER XXII. 
Finishing Gold Fillings 137 

CHAPTER XXIII. 
Manipulation of Amalgam in the Making of a Filling 139 

CHAPTER XXIV. 
The Use of Cements in Filling Teeth 1-46 

CHAPTER XXV. 
Manipulation of Silicate in the Making of a Filling 148 

CHAPTER XXVI. 
The Use of Gutta-Percha in Filling Teeth 164 

CHAPTER XXVII. 
Tin as a Filling Material 166 

CHAPTER XXVIII. 
Combination Fillings 169 



CONTENTS 11 

PART III. 

CHAPTER XXIX. Page 

Examination of the Mouth Looking to Dental Services ...... 174 

CHAPTER XXX. 
The Alleviation of Dental Pains 177 

CHAPTER XXXI. 
Prophylactic Treatment of the Mouth 180 

CHAPTER XXXII. 
Exclusion of Moisture 187 

CHAPTER XXXIII. 
Treatment of Hypersensitive Dentine 195 

CHAPTER XXXIV. 
Protection of the Vital Pulp 204 

CHAPTER XXXV. 
Pulp Devitalization and Removal 211 

CHAPTER XXXVI. 
Management of Putrescent Pulp Canals 219 

CHAPTER XXXVII. 
The Filling of Pulp Canals 225 

CHAPTER XXXVIII. 
Management of Children's Teeth 229 

CHAPTER XXXIX. 
Extraction of Permanent Teeth 233 

CHAPTER XL. 
Extraction of Temporary Teeth 269 

CHAPTER XLI. 
Local and Regional Anesthesia 275 

CHAPTER XLII. 
The Use of Fused Porcelain in Filling Teeth 293 

CHAPTER XLIII. 
Preparation of Cavities for Porcelain Inlays 296 

CHAPTER XLIV. 
The Construction and Placing of a Porcelain Inlay 306 



ILLUSTRATIONS 



FIG. PAGE 

1. Defects in enamel 21 

2. Defects in enamef . 22 

3. Smooth surface decay 23 

4. Smooth surface decay 23 

5. Class One cavities filled 24 

6. Class Two cavity filled 24 

7. Class Three cavity filled 25 

8. Class Four cavity filled 25 

9. Class Five cavity filled 25 

10. Bisected molar in which a mesial Class Two cavity has been cut and line 

angles indicated 26 

11. Bisected molar in which a mesial Class Two cavity has been cut and point 

angles indicated 26 

12. Diagram of tooth, giving angles and surfaces 27 

13. Technic group illustrating outline form 35 

14. Another view of cavities illustrated in Fig. 13 '. . . 35 

15. Fillings in place in cavities shown in Figs. 13 and 14 36 

16. Another view of fillings shown in Fig. 15 36 

17. Complex Class One cavity prepared 50 

18. Class One filled. Cavity shown in Fig. 17 51 

19. Large Class One cavities prepared 53 

20. Class One filled. Cavities shown in Fig. 19 54 

21. Lingual pit cavities 55 

22. Class One filled. Cavities shown in Fig. 21 56 

23. One of the few cases in which the step may be omitted in Class Two 

cavities 60 

24. Class Two cavities in molar and bicuspid suitable for cohesive gold or 

amalgam 61 

25. Class Two filled. Cavities shown in Fig. 24 62 

26. Fillings shown in Fig. 25 contacted, illustrating the marble contact . . 63 

27. Large Class Two cavities in non-vital teeth restoring part of the occlusal 

surface for the protection of weakened walls 67 

28. Class Two filled. Cavities shown in Fig. 27 . 67 

29. Mesio-occluso-distal cavities in molar and bicuspid, vital teeth .... 68 

30. Mesio-occluso-distal fillings. Cavities shown in Fig. 29 68 

31. (A) First superior molar, non-vital, restoring the lingual cusps. (B) 

Second superior bicuspid, non-vital, restoring the entire occlusal 

surface 69 

32. Class Two filled. Cavities shown in Fig. 31 69 

33. Class Three cavities filled 73 

34. Drawing to illustrate the retention at the incisal angle of Class Three 

cavity 75 

35. Class Three cavities prepared for cohesive gold 76 

36. Class Three filled. Cavities shown in Fig. 35 76 

37. Drawings to illustrate the principle of the lever in the dislodgement of 

fillings of the Fourth Class, plan one 79 

38. Drawings to illustrate the principle of the lever in the dislodgement of 

fillings of the Fourth Class, plans one and two SO 

39. Drawing to illustrate the difference in the directions the point angle 

fillings take in tipping to exit with various fillings 82 

12 



ILLUSTRATIONS 13 

FIG. PAGE 

40. Drawings to illustrate the importance which should be given to the proper 

placing of the incisal point angle in fillings of Class Four, plan two 88 

41. A study in the proper placing and depth of the gingival angles ... 84 

42. A study of the planes in which the gingival angles should be laid . . 84 

43. Cavity of Class Four, plan one, for cohesive gold . 85 

44. Class Four, plan one, cavity filled 85 

45. Shows incisal outline in Class Four, plan one, fillings with direct occlusion 86 

46. Cavity of Class Four, plan two, for cohesive gold 88 

47. Class Four, plan two, filled 88 

48. Cavity of Class Four, plan three, for cohesive gold • . 89 

49. Class Four, plan three, filled 89 

50. Cavity of Class Four, plan four, for cohesive gold 91 

51. Class Four, plan four, filled 91 

52. Cavity of Class Four, modified plan three, for cohesive gold in the distal 

of the superior cuspid 92 

53. Class Four, modified plan three, filled 92 

54. Cavities Class Five for cohesive gold or amalgam 93 

55. Class Five filled 94 

56. Cavities of Class One for gold inlays 101 

57. Class One inlay in position showing gold wire cast in the filling . . . 102 

58. Cavities of Class Two for gold inlays 103 

59. Cavity of Class Three for gold inlay, lingual approach 105 

60. Inlay shown in Fig. 59 partly in place 105 

61. Cavity of Class Four, plan one, for gold inlay 106 

62. Class Four, plan one, inlay in position 106 

63. Cavity of Class Four, plan two, for gold inlay 107 

64. Class Four, plan two, gold inlay in position 107 

65. Cavity of Class Four, plan three, for gold inlay 108 

66. Class Four, plan three, inlay in position .■ 108 

67. Cavity of Class Four, plan four, for gold inlay 109 

68. Class Four, plan four, showing cavity side of pattern with pins . . . 109 

69. Class Four, plan four, inlay in position before removing wire loop . . 109 

70. Class Five cavity and inlay 110 

71. Show^s the necessary amount of metal for adequate protection of abraded 

surfaces, when opening the bite 110 

72. Large restoration in non-vital case 113 

73. Some of the methods by which inlays may be given retentive form in 

large decays and non-vital cases 135 

74. Starting cohesive gold, first plan 130 

75. Starting cohesive gold, second plan 131 

76. Starting cohesive gold, third plan 132 

77. Burnishing back excess gold foil in covering the gingival margin . . 133 

78. Covering the gingivo-lingual angle with cohesive gold 134 

79. Suitable cavities for the use of silicate fillings 149 

80. A Class One cavity on the labial of a central incisor properly prepared 

for a silicate filling 149 

81. Extensive Class Three cavity properly prepared for a silicate filling . . 150 

82. A Class Five and a Class Three cavity suitable for the use of silicate 

as a filling - 150 

83. A Class Five cavity properly prepared for a silicate filling 151 

84. A Class Three cavity, lingual approach, properly prepared for a silicate 

filling . . .' 151 

85. A small Class Three cavity, labial approach, properly prepared for a 

silicate filling: 152 



14 ILLUSTRATIONS 

FIG. PAGE 

86. A small Class Three cavity, lingual approach, properly prepared for a 

silicate filling 152 

87. A large Class Three cavity, labial approach, properly prepared for a 

silicate filling 152 

88. A large Class Three cavity, lingual approach, properly prepared for a 

silicate filling 152 

89. A large Class Three cavity properly prepared for a silicate filling . . 153 

90. Two extensive Class Three cavities properly prepared for a silicate 

filling ' 153 

91. A small set of instruments for manipulating silicate 15-1: 

92. A suitable slab and spatula for working silicate 155 

93. Proper position of the spatula on the slab when manipulating silicate 156 

94. Proper placing of the materials when manipulating silicate .... 156 

95. Mixing the silicate filling 157 

96. Mixing the silicate filling 157 

97. Circular motion used in mixing the silicate filling 15S 

98. Scraping the material from the slab 15P 

99. The entire mix on the spatula 160 

100. Method of removing the mix from the spatula to the slab . ... . . 160 

101. Proper consistency of silicate 161 

102. Shows mix of silicate too thin 161 

103. A homemade mallet and point 162 

104. Three cavities suitable for silicate fillings 163 

105. Shows the results obtained after filling with silicate the cavities shown 

in Fig. 104 163 

106. Combination gold inlay and silicate 171 

107. Amalgam in position ready to receive a partial facing of silicate . . 172 

108. Amalgam filling shown in Fig. 107 with the silicate facing built in . 172 

109. An improper position with the operator doing his work at arm's length 235 

110. Types of superior central incisors 236 

111. Types of superior lateral incisors 237 

112. Position for extracting superior incisors 238 

113. Types of inferior central and lateral incisors 239 

114. Position for extracting lower incisors 240 

115. Types of superior cuspids 241 

116. Position for extracting right superior cuspids 242 

117. Position for extracting left superior cuspids 243 

118. Mesial and distal application of forceps to a superior right cuspid 

when both adjacent teeth have been extracted 244 

119. Types of inferior cuspids 246 

120. Position for extracting inferior cuspids 247 

121. Types of superior first and second bicuspids 248 

122. Position for extracting right superior bicuspids 249 

123. Position for extracting left superior bicuspids 250 

124. Types of inferior first and second bicuspids 251 

125. Position for extracting right inferior bicuspids 252 

126. Position for extracting left inferior bicuspids 253 

127. Types of superior first and second molars 254 

128. Position for extracting first and second right superior molars . . . 255 

129. Position for extracting first and second left superior molars . . . 256 

130. Types of inferior first and second molars 257 

131. Position for extracting first and second right inferior molars . . . 25S 

132. Position for extracting first and second left inferior molars .... 259 

133. Types of superior third molars 260 



ILLUSTRATIONS 15 

FIG. PAGE 

134. Types of abnormal superior third molars . . . 261 

135. One of the many abnormal conditions found when extracting upper 

second and third molars 262 

136. Position for extracting right upper third molars 263 

137. Position for extracting upper left third molars 264 

138. Types of inferior third molars 265 

139. Elevator beaked forceps for extracting third molars 266 

140. Position for extracting right inferior third molars 266 

141. Position for extracting left inferior third molar ........ 267 

142. Complete set of deciduous teeth with the first permanent molar added . 270 

143. Irregularity resulting from premature extraction of first deciduous molar 271 

144. Horizontal injection 275 

145. Perpendicular injection 276 

146. Drawing representing the positions of needles in local anesthesia . . 277 

147. First position in the mandibular injection 278 

148. Second position in the mandibular injection 279 

149. Third position for the mandibular injection 280 

150. Fourth and last position for the mandibular injection 281 

151. A very clear and easy case with the needle in the best position for the 

mandibular injection 282 

152. A difficult case where the lingula is almost entirely wanting .... 283 

153. Same mandible as shown in Fig. 153 with the needle passed to position 

sufficiently high to be above the lingula 284 

154. A mandible which belongs to a class on which it is very hard to give 

a mandibular injection 285 

155. First and ideal position for giving the mental injection 286 

156. Second position for giving the mental injection 287 

157. Position of needle in giving the infra-orbital injection 289 

158. Final position of the needle in giving the zygomatic injection . . . 291 

159. Cavity preparation for a Class Two porcelain inlay 297 

160. A Class Three cavity labial approach for porcelain inlay 298 

161. A Class Three cavity labial approach for porcelain inlay 298 

162. A Class Three cavity lingual approach for porcelain inlay 299 

163. A Class Four cavity incisal approach for porcelain inlay 300 

164. A Class Four, plan one, inciso-proximal approach for porcelain inlay 300 

165. A Class Four, plan two, with double step for porcelain inlay .... 301 

166. A Class Four, plan three, for porcelain inlay 302 

167. Class Five cavities for porcelain inlay 303 

168. Incisal cavity for porcelain inlay 304 

169. A Class Six cavity using pin anchorage for porcelain inlay .... 305 

170. Chisels for securing outline form 314 

171. Spoons for removing softened dentine 315 

172. Enamel hatchets for completing outline form and flattening dentine 

walls 316 

173. Instruments for cutting point angles and sharpening base line angles . 317 

174. Hatchets and hoes for cutting ascending line angles and completing 

retention form 318 

175. Gingival marginal trimmers 319 

176. Gold building pluggers 320 

177. Dr. Rathbun's dentech with teeth in position ready for practice work 321 

178. A student who has kept his appointment with his patient, ^'Mr. Den- 

tech" 322 

179. Forceps made after the patterns of the author 323 

180. Forceps made after the patterns of the author 324 



OPEEATIYE DENTISTRY 



PART I 

CHAPTER I. 
INSTRUMENT NOMENCLATURE. 

A dental instrument is an appliance, or tool, by means of Avhicli 
a dentist performs dental operations. It is quite essential that we 
learn the names and uses of the instruments most in use if we are 
to understand the teaehng of operative procedures. 

Instruments are named according to the purpose for which they 
are intended, Avhere and hoAV used, by describing their working 
points and the shape of their shank. 

An order name describes that for which an instrument is used, 
as for example, excavator, clamps, mallet, pluggers, burnishers, etc. 

A sub-order name describes Avhere or how an instrument of a 
given order is used and is made b}^ inserting a prefix before the or- 
der name. Examples are hand pluggers, push or pull scalers, etc. 

A class name describes the working point of an instrument. Ex- 
amples are serrated plugger, ball burnisher, chisel, hatchet, etc. 

A sub-class name describes the shape of the shank, and is made 
by prefixing this description to the class or order name or to both 
combined. Examples are bayonet plugger, bin-angle chisel, mon- 
angle hatchet excavator, etc. 

Rights and lefts are made as further divisions of many of the 
sub-classes of instruments and this division is especially advan- 
tageous in the spoons, bin-angle, contra-angle hatchets and mar- 
ginal trimmers, as it enables the user to do the work by a move- 
ment of the instrument from right to left, or left to right, respec- 
tively. 

An excavator is that order of hand instrument used in the re- 
moval of tooth substance preparatory to the making of a filling. 

A chisel is that class of excavator which has the cutting edge 
placed at right angles to the shaft, is sharpened by grinding on 

17 



18 OPERATIVE DENTISTRY 

cue side only and is used by a pushing force applied in the direc- 
tion of the long axis of the shaft. 

The chisel edge is made with a bevel at an angle calculated to 
plane and cleave a substance possessed of a grain, and is so tem- 
pered as to retain an edge Avhen working on hard substances. 

The use of the chisel is, therefore, the cleaving and planing of 
enamel. The planing of dentine may be done with a chisel or with 
other instruments of a similar edge. 

Chisels are divided into sub-classes according to the shapes of 
their shanks, as straight, bin-angle, contra-angle, etc. 

A hoe is that class of excavator with the cutting edge at a right 
angle with the shaft, sharpened on the distal side only and is used 
by a pulling force applied parallel with the long axis of the shaft. 

Hoes are divided into sub-classes according to the shape of their 
shanks, as, mon-angle, bin-angle, contra-angle and triple-angle con- 
tra-angle. The hoe is used mostly for cutting dentine. 

A hatchet is that class of excavator with the line of the cutting 
edge laid in the plane parallel with the long axis of the shaft. 

Hatchets are divided into sub-classes the same as the hoes, ac- 
cording to the shape of their shank, as, mon-angle, bin-angle and 
triple-angle contra-angle. The hatchet form is indispensable for the 
construction of flat walls and internal surfaces, the straightening 
of lines and the sharpening of angles. 

A gingival marginal trimmer is a modified hatchet. 

A spoon is that class of excavator Avhich resembles in most re- 
spects the hatchet, other than the cutting edge. This is sharpened 
on one side only which is rounded like the convex side of the bowl 
of a spoon from which it derives its name. The cutting edge is 
rounded and sharpened to a thin edge. Spoons are always made 
rights and lefts. 

The use of a spoon is to remove foreign matter and softened 
dentine from the tooth cavity. 

The angles between the shank and the Avorking part are desig- 
nated as mon-angle, bin-angles, and triple-angles, according to the 
number of angles used being one, two or three, respectively. 

The contra-angle is the placing of such angles in the shank of 
the instrument as to bring the cutting edge near the central line 
of the shaft which removes the tendency to tip or turn in the hand 
during use. 

Bin-angles and triple-angles are properly made only when con- 
tra-angled, provided the cutting edge is more than three millimeters 
from the central line of the shaft. 



INSTRUMENT NOMENCLATURE 19 

Formula Names. Some instruments have the formula stamped 
on the handle in figures. There are generally three numbers given. 
The first is the width of the blade in tenths of a millimeter. The 
SiCcond is the length of the blade given in millimeters. The third 
is the angle of the blade with its handle given in the hundredths 
of a circle. 

AVhen a four-number formula is given, as with gingival marginal 
trimmers, the second number in the name designates the angle of 
the cutting edge of the blade with shaft or handle. This is also 
given in the hundredths of a circle. 

A plugger is an order of instrument for the packing of material 
in the making of a filling. Those for gold are serrated on the work- 
ing point in such shape as to result in a surface made up of prisms. 
These prisms should be of exactly the same size on all the points 
used in any individual filling when packing cohesive gold, as the 
interchange of points of different-sized serrations causes bridging. 
(See manipulation of cohesive gold. Chapter XX.) 

The dental engine is almost indispensable and when properly used 
is a blessing to our patients and a time-saver to the dentist. How- 
ever, it is all too frequently used, especially by students and young 
practitioners, to do things which can properly be done only wdth 
the hand instruments. The misuse of the dental engine has caused 
the public to regard it asthe climax of all pain-producing instru- 
ments in the dental office, v/hen in reality, if that which should be 
done with the engine is properly done, only a few seconds of pain is 
induced in the preparation of a very severe cavity. 

The engine bur is the working point of the engine and is made 
in many shapes and sizes. However, those which are round and in- 
verted cones, whose diameter is smaller than one millimeter, are 
most frequently indicated. The tendency of the beginner is to use 
too large burs. Burs are primarily intended to cut dentine in out- 
lining cavitj^ walls, and for undermining enamel to facilitate the 
use of hand instruments and they should rarely come in contact 
with the enamel. 

The most indispensable use of the engine is for the polishing and 
grinding necessary to the successful termination of manj^ varied 
operations, both in and out of the mouth. 

The sharpening of instruments is of the utmost importance and 
is by no means accomplished without skill. No better can a dentist 
execute finished work than can a tradesman whose tools must be 
keen of edge if he is to produce that which is worthy of his craft. 
Again, dull instruments cause an undue amount of pain at each at- 



20 OPERATI^^E DENTISTRY 

tempt to cut, whereas when sharp, the pain is less and the effort 
in cutting is materially lessened, resulting in a saving of pain to 
the patient and time and energy to the dentist. A hard, smooth 
Arkansas stone* is the only suitable abrasive and should be well 
oiled and Aviped with a cloth after each use. 

Care of Instruments. As the instruments are shipped to the den- 
tist they are usually made and sharpened especially for the use in- 
tended and care should be exercised in sharpening that the degree 
of the angle of the beveled edge is not changed. 

Tests for Sharpness. An instrument is tested for sharpness best 
by placing the edge with light pressure against the finger nail and 
attempting to move it across the surface at right angles to the 
edge. If it catches or clings to the nail it is ready for use. 



CHAPTEE 11. 
CAVITY NOMENCLATURE. 

A cavity nomenclature is necessary that we may understand one 
another in conversing about the formation of cavities, the descrip- 
tion of their several parts and the methods of procedure in the 
preparation of cavities for fillings. 

Cavities derive their names from the surfaces of the teeth in 
which they occur. Thus occlusal cavity, buccal cavity, labial cav- 
ity, etc., are cavities occurring in the surfaces named. 




Fig. 1. — Defects in enamel. 

Proximal cavities are those occurring in the proximal surfaces 
and are divided into two classes, namely, mesial and distal. 

A simple cavity is one which involves but one surface. 

A complex cavity is one which, either from decay or extension 
in preparation, involves more than one surface. 

Complex cavities are named by combining the names of the sur- 
faces of the tooth involved, as mesio-occlusal, disto-occlusal, mesio- 
disto-occlusal, etc. 

An axial surface cavity is one which occurs in an axial surface. 

Cavities are divided as to their origin into two groups. 

First. Pit and fissure cavities, which are those originating in 
the minute faults in the enamel. (See Figs. 1 and 2.) 

21 



22 OPERATIVE DENTISTRY 

Second. Smooth surface cavities, which are those occurring on sur- 
faces without defects in the enamel, but are habitually unclean. 
(See Figs. 3 and 4.) 

Cavities are divided according to similarity in line of treatment 
into six divisions. 

Class One. Those cavities beginning in structural defects. (Pits 
and fissures.) 

Class Two. Those cavities in the proximal surfaces of bicuspids 
and molars. 

Class Three. Those cavities in the proximal surfaces of incisors 
and cuspids not involving the incisal angle. 




Fig. 2. — Defects in enamel. 

Class Four. Those cavities in the proximal surfaces of incisors 
and cuspids Avhich require the restoration of the incisal angle. 

Class Five. Those cavities in the gingival third of the labial, 
buccal and lingual surfaces not originating in faults in enamel. 

Class Six. Abraded surfaces. 

The outside walls of a cavity are those walls placed toAvard the 
outside surfaces of a tooth and take the names of the surfaces of 
the tooth toward which they are placed, as in an occlusal cavity 
the outside walls are buccal, distal, mesial and lingual, while the 
fifth or internal wall is the pulpal. 

The pulpal wall is that inside wall of a cavity which covers the 
pulp and is in a plane at right angles to the long axis of the tooth. 



CAVITY NOMENCLATURE 



23 



In case tJie pulp is removed the pulpal wall becomes the sub- 
pulpal wall, in multi-rooted teeth. 

The axial wall is the inside wall of an axial surface cavity which 
covers the pulp and is in a plane parallel to the long axis of the 
tooth. 




Fig. 3. — Smooth surface decay. 




Fig. 4. — Smooth surface decay. 



I7i case tlie pulp is removed in an axial surface cavity the axial 
wall becomes an outside Avail and takes the name of the surface of 
the tooth toward which it is placed. 

The gingival wall is the inside wall of an axial surface cavity 



operatrt: dentistry 



placed toward, and running in the same plane as, the gingivae. 

Both gingival and sub-pulpal walls may be present in cases of 
pulp removal in mesio-occlusal, disto-occlusal, and mesio-disto-oc- 




Fig. 5. — Class One cavities filled. 




Fig. 6. — Class Two cavity tilled. 



clusal cavities when each is on a different level and the individuality 
of each Avail is retained. 

The inside walls of a cavity are those placed toward the pulp or 
root of a tooth. 



CAVITY NOMENCLATURE 



25 



The base of a cavity, or seat of a filling, is that portion of a cav- 
ity situated at right angles to the lines of force to which it is most 
likely to be subjected. Generally speaking, this is the gingival or 
pulpal wall, or both, where these w^alls are present, as in a step 
cavitv. 





Fig. 7. — Class Three cavity iilled. 



Fig. 8. — Class Four cavity filled. 




Fig. 9. — Class Five cavity filled. 

A line angle is formed where two walls of a cavity meet along 
a line and is named by joining the names of the walls so meeting. 

Tliere is hut one exception to this rule. That is where the labial 
and lingual walls of a proximal cavity in the incisors and cuspids 
meet along a line. By applying the rule this would be called the 



/ 



26 



OPERATIV-E DENTISTRY 



labio-lingual angle, but for convenience this is named the/'incisal- 
line angle." 

A point angle is formed where three Avails of a cavity meet at 





^^^^^^ ^^^^^^^^^^^^^^^^^H 


L± 


-^H 



A B 

Fig. 10. — Bisected molar in which a mesial Class Two cavity has been cut and line angles 
indicated. The line angles arc: a, Gingivo-buccal ; b, Gingivo-lingual; c, Gingivo-axial; d, 
Axio-buccal; c, Axio-lingual; /, Axio-jjulpal ; g, Pulpo-buccal; /i, Pulpo-lingual; i", Pulpo-distal; 
j, Disto-buccal; k, Disto-lingual. 




A B 

Fig. 11. — Bisected molar in which a mesial Class Two cavity has been cut and point angles 
indicated. The point angles are: a, Gingivo-axio-buccal ; h, Gingivo-axio-lingual; d, Puloo-disto- 
lingual; c, Pulpo-disto-buccal. 



a point and is named by joining the names of the walls so meeting. 
Tliere is hut one exception to this rule. The point of junction of 



CAVITY NOMENCLATURE 



27 



the axial, labial and lingual walls in proximal cavities in the six 
anterior teeth is, for convenience, named the '4ncisal angle." 

A simple cavity has two sets of line angles. First, the internal 
line angles surrounding the internal wall, which is the axial wall 
in axial surface cavities, and the pulpal wall in occlusal cavities. 

The second set of external line angles is formed by the junc- 
tion of the outside walls with each other. 

The enamel margin is that point on the surface of the tooth 
where the cavitv begins in enamel. 




Fig. 12.— A, External enamel surface; B. Cavo-surface angle; C, Marginal bevel; D, Bevel 
angle; E, Enamel wall; F, Dento-enamel junction; G, Dentinal wall; H, Base line angles. 



The external enamel line is the entire outline of the cavity at 
its enamel margin. 

The cavo-surface angle is the angle formed by the junction of 
the wall of the cavity with the external surface of the tooth. 

The base of the cavo-surface angle is the external enamel surface. 

The marginal bevel of a cavity is the deflection of a cavity wall 
from its established plane, near the external enamel line. 

It is necessary that beveling be resorted to, in order to manage 



28 OPERATIVE DENTISTRY 

the enamel margins, direct the external enamel line and control 
the degree of the cavo-surface angle, withont disturbing the gen- 
eral retentive form of the cavity. 

The bevel angle is the angle formed by the junction of the mar- 
ginal bevel with the remaining portion of the wall of which it is a 
part. 

The base of the bevel angle is the remaining portion of the cavity 
wall. 

The bevel angle is covered Avhen the filling is in position. Its 
distance from the enamel margin depends upon the filling material 
used, and the location in the cavity outline. To illustrate: With 
porcelain inlays and amalgam the bevel angle must be deeply bur- 
ied, resulting in a thicker edge of filling material. With cast gold 
inlays and platinum combination fillings the bevel angle should be 
near the surface, resulting in a short marginal bevel. The distance 
of the bevel angle from the cavo-surface angle must not affect the 
degree of the latter angle but determines only the length of the 
bevel and the thickness of the filling at its margin. 

The planes of a tooth are three in number ; horizontal plane, mesio- 
distal plane and bucco-lingual plane. 

The horizontal plane is at right angles to the long axis of the 
tooth. 

The mesio-distal plane passes through the tooth from mesial to 
distal parallel with the long axis. 

The bucco-lingTial plane passes through the tooth from buccal to 
lingual parallel with the long axis of the tooth. In the six anterior 
teeth this plane would be labio-lingual. 



CHAPTER III. 
CAVITY PREPARATION. ( GENERAL CONSIDERATIONS. ) 

Definition of Cavity Preparation. Cavity preparation is that term 
applied to those mechanical procedures upon a tooth, looking to 
the making of a filling, as well as those changes and extensions 
necessary to resist stress and prevent a recurrence of decay. 

Affected Dentine is dentine which has been acted upon by the 
lactic acid in advance of the micro-organisms of caries. 

Infected Dentine is dentine which has been penetrated by micro- 
organisms. 

Objects in Filling Teeth. There are four general objects in view 
in the filling of teeth : 

First. — To arrest the loss of tooth substance. 

Second. — To prevent recurrence of caries. 

Third. — To restore full tooth contour. 

Fourtli. — To improve the primary conditions as to the perform- 
ance of function and esthetic effects. 

A Completed Cavity should be a combination of flat walls com- 
ing together at definite angles, surrounded by an external line made 
up of the largest curves permissible. 

The Line Angles within a cavity, which are a necessary part of 
resistance and retention forms, should never be permitted to end 
in the external enamel line. 

Order of Procedure. To simplify the preparation of all cavities 
and to insure the observance of certain fundamental principles it 
is well to follow a definite order of procedure. This will greatly 
facilitate the operations of the student and lead to the establish- 
ment of habits by the practitioner which will stand for thorough 
methods of execution. 

The following would seem to be the natural order : 

First. — Gain access. 

/S^econcZ.^Outline form. 

Tliird. — Resistance form. 

Fourth. — Retention form. 

Fifth. — Convenience form. 

Sixth. — Removal of remaining decay. 

Seventh. — Finishing of enamel walls. 

£"2(771^71.— Toilet of the cavity. 

29 



30 operatimj: dentistry 

Modification of Form is necessary in cavity preparation to meet 
the various properties of the different filling materials used. This 
is particularly true when considering the difference in edge strength 
and flow of metals and alloys. 

The character of the oral fluids, the evident care bestowed upon 
the teeth, condition of patient's health, age of patient and the life 
expectancy of the patient and of the individual teeth, will fre- 
quently require a modiflcation of cavity formation to best resist 
the recurrence of decay and the dislodgement of the filling through 
stress. 



CHAPTER IV. 
GAINING ACCESS. 

Definition. Gaining access is the term applied to those proced- 
ures necessary to make sufficient room for the proper introduction 
of the filling. 

Sufficient Access is Important, that we may have the advantage 
of space to properly handle the instruments and appliances used 
in the procedures of making a filling, that we may be able to intro- 
duce the filling into the cavity, that there may be complete contour 
restoration of tooth form and that the desired contact relation may 
be established to the adjacent tooth. 

Access to the Tooth is the first consideration and will involve 
the opening of the mouth to a sufficient degree to permit of the 
free use of the usual appliances. The proximal spaces used for the 
adjustment of the dam should be examined to make sure that the 
rubber and ligatures will pass to the gingival line without injury. 
A sufficient number of teeth should be isolated, say four or five, 
to give a clear and unobstructive view of the cavity and surround- 
ing teeth. 

The operator must be able to bring the cavity into full Adew. 
Cases where there has been considerable deca}' sub-gingivally, and 
tumefaction of the gum septa has taken place, proper access Avill 
involve the packing of the cavity with a tampon of cotton which 
has been dipped in chlora-percha, or a packing of gutta-percha, 
for a period of twenty-four or forty-eight hours, to crowd the en- 
croaching gum tissue from the cavity. A neglect of this considera- 
tion of access will often make proper management of the gingival 
wall and margin most difficult or impossible. 

Surgical Access may be practiced on the cavity margins, when 
all tooth structure thus removed Avill subsequently be replaced Avith 
filling material. It may be practiced on the gum septa when there 
has been excessive tumefaction in the proximal space. 

Formerly this method was practiced with Class Five cavities 
where the decay was to a marked extent subgingival, and it was 
desired to make a cohesive gold filling. However, much of this 
questionable practice may now be avoided by the use of the gold 
inlay, made from the wax model, as the presence of the overlying 
gum is no considerable hindrance. 

Access as Related to Restoration of Proximal Space. As tooth 

31 



oZ OPERATR-E DENTISTRY 

substance is lost through decay in proximal cavities, there is in 
most cases a movement of the teeth to the proximal, encroaching 
on the normal space, robbing the gum of sufficient room for full 
festoon. It is wholly impossible in such cases for the operator in 
making a filling to restore tooth contour, or leave a normal amount 
of room for the rehabitation of the gum septa, without resorting 
to separation. The surfaces of a tooth which are covered Avith 
healthy gum tissue are practically immune from both primary and 
secondary caries, and it is greatly to the advantage of a filling, the 
outline of which in the proximal gingival third, to be so protected. 
Good access should be gained by preliminary separation, so that 
when the completed filling with its full tooth-form restoration is 
in place, there is restored the normal proximal space for the habita- 
tion of the gum septa. A failure to regard this fact will result in 
a strangulated, diseased and dwarfed septa, inviting an accumula- 
tion of the enemy of tooth structure and an early loss of the filling 
through secondary caries. 

Restoration of Tooth Form is essential that the full function of 
the masticating organs may be established and maintained. It is 
also desirable for esthetic reasons, as the more nearly a dentist 
approaches complete tooth contour restoration, with all its details, 
the more pleasing is the appearance and the more artistic the 
result. 

Proper Contact Point is often impossible unless sufficient ac- 
cess has been secured through separation. This contact should 
be a point of contact, the embrasures Avidening therefrom in every 
direction. It should be in no sense a line of contact or a surface, 
no matter how small. It is advisable many times, in this respect, 
to improve on nature by slightly varying the surface of the filling 
from the original shape of the tooth, as often the predisposing cause 
of the primary decay has been defective contact. 

The Saving of Tooth Substance is materially effected by access 
through preliminary separation, particularly in the placing of in- 
lays, as the more thoroughly this first step in procedure has been 
accomplished the less cutting will be required for convenience form, 
a point of no small importance. 

Methods of Separation. There are two classifications of separa- 
tion to gain access, preliminary, which is also sIoav separation, and 
immediate, which is rapid, both of which are a part of gaining ac- 
cess. 

The preliminary is a part of the first consideration, while im- 



GAINING ACCESS 33 

mediate separation is brought to our attention during the introduc- 
tion of the filling. 

Preliminary Separation is best accomplished in proximal cavities 
in bicuspids and molars (Class Two) by packing into the partially 
excavated cavity an excess of gutta-percha base plate. A few days, 
or in some instances a few Aveeks, will suffice to accomplish the 
desired result, particularly if the patient uses that location in the 
mouth for daily mastication of solid food. 

In the proximal space in the six anteriors preliminary separa- 
tion is best accomplished by the use of cotton tampons tightl}^ 
packed in the cavity and ligatured securely to position. 

Immediate Separation is best accomplished with the mechanical 
separator, and should be used to gain additional access, not already 
secured by preliminary separation, or may be used primarily when 
only a small amount of additional space is desired. This instru- 
ment should be adjusted as soon as convenient after securing out- 
line form, and removed only when the filling is finished. 

Avoid Gum Injuries in the use of elastic rubber. In the use of 
the methods given care should be used not to crowd the gum tissue 
as permanent injury may result. 

There are other materials used in slow separation, as linen tape, 
"wooden wedges, etc., each with its merit and indicated use. 

Soreness Resulting from Tooth Separation should be treated as 
any case of acute pericementitis, by giving the tooth physiological 
rest, and the use of stimulating applications on the gum over the 
tooth's root. 



CHAPTER Y. 
OUTLINE FORM. 

Definition. Outline form is that part of cavity preparation ^vhicli 
determines the area of the tooth surface to be included Avithin the 
external enamel line. 

Rule 1. Extend to Sound Enamel. All caA^ty margins should 
be extended until all indications of surface decay ha^-e been in- 
cluded. 

Rule 2. Obtain Full Length Rods. If necessary, further extend 
the outline until full-length enamel rods, supported by sound den- 
tine, have been reached. 

Rule 3. Self-Cleansing Margins. Extend the caA^ty outline un- 
til the surface of the filling can be so formed that the enamel mar- 
gin not protected by the gum Avill be mechanically cleansed by the 
excursions of food in mastication. 

Rule 4. In Relation to Developmental Grooves. A cavity out- 
line should not folloAv a developmental groove, or parallel it so 
closely as to leave a small strip of intervening enamel. The outline 
should cross the grooves as squarely as possible. 

Rule 5. Fissures and Sulcate Grooves. All fissures, sulcate 
grooves and angular developmental grooves encountered should be 
included AA'ithin the cavity outline. This comes in for the greatest 
consideration Avhen part of the outline is laid on an occlusal sur- 
face. 

Rule 6. Enamel Eminences. The outline should avoid extreme 
eminences of enamel and centers of primary dcA^elopment. Such 
locations are subject to the extremes of stress during mastication. 
When the eminence in question is the seat of primary calcification 
it AA'ill be found to be less perfect in formation than the portion 
midAvay from that point to the grooA^es. 

Rule 7. Avoid Angles in Outline. The outline should be made 
up of the greatest curves possible, avoiding all angles. Nearly flat 
axial surfaces should shoAv nearly straight lines or the segments 
of A^ery large circles, Avhile on occlusal surfaces, AAiiich are made up 
of a succession of depressions and eminences, the outline should 
be a combination of smaller curA^es. 

Rule 8. Outline in the Embrasures. The outlines in the labial, 
buccal and lingual embrasures should be parallel to each other and 

3i 



OUTLINE FORM 35 

at right angles to the seat of the cavity, and pass under the free 
margin of the gum at a point in full view of the operator. 

Rule 9. Enamel Margins. The enamel margins should be planed 
smooth to a full cleavage of the enamel rods and then slightly 
beveled that the rods at the cavo-surface angle may be full-length 




Fig. 13. — Technic group illustrating outline form. 




Fig. 14. — Another view of cavities illustrated in Fig. 13. 

rods, supported by shortened enamel rods which are protected by 
the overlying filling material. 

Rule 10. Extension for Prevention. When possible, carry the 
cavity outline upon smooth, unclean surfaces, from an area of great 
liability to caries to an area of lesser liability to caries. 

This has reference to caries of enamel onlj^ and will come into 



36 



operatrt: dentistry 



consideration in cavity outline when the rules previously given 
have not carried the outline to comparatively safe and immune 
localities. 




Fig. 15. — Fillings in place in cavities shown in F'igs. 13 and 14. 




Fig. 16. — Another view of fillings shown in Fig. 15. 

Extension for prevention does not mean tlie eonsidcration of re- 
sistance to stress. It bears no reference to decay of the dentine. It 
has no relation to the manao-ement of frail walls. 



J 



OUTLINE FORM 37 

Its maximum application is found in the management of small 
cavities where the ravages of decay have not yet carried the out- 
line of the cavity to areas not subject to primary enamel dissolu- 
tion. 

Tlie abuses of extension for prevention result in much unneces- 
sary loss of tooth substance, while its sane and legitimate use is one 
of the most important factors in tooth salvage. 

Dangers of Increased Cavity Outline. The danger of secondary 
caries increases in each mouth proportionately as the aggregate 
length of cavity outline is increased. 

To Illustrate. If the total length of cavity outline of all fillings 
in a mouth is doubled by the increase in number of fillings the 
liability to secondary caries is doubled, all else being equal. For 
that reason each individual cavity should have its outline as short 
as permissible. 

The laying of cavity outline in locations not susceptible to pri- 
mary caries will materially decrease the liability to recurrent de- 
cay, even though the aggregate cavity outline in the mouth is 
thereby greatly lengthened. An aggregate cavity outline of two 
feet is preferable to a total of one foot, provided the additional 
length has been caused to extend to locations not liable to caries. 



CHAPTER VI. 
RESISTANCE FORM. 

Definition. — Extension for resistance is a term applied to that 
procedure which has for its sole object the carrying of the cavity 
outline from localities subjected to great stress, to localities not 
frequently subjected to the crushing strain. This is often mistaken 
for extension for prevention, whereas it has reference only to re- 
sistance to stress. 

A proper application of this procedure will involve a careful 
study of occlusion and articulation in each individual case. 

Resistance form involves a consideration of the management of 
weakened enamel walls and a study of the flow and edge strength 
of the filling material used with a view of so shapin'g the cavity 
as to minimize the effects of the crushing strain. 

Its importance is in direct proportion to the exposure of the fill- 
ing in occlusion and articulation, and the strength of the closure 
of the jaws. 

The force to provide for is from one to two hundred pounds and 
in some cases even more, particularly in mid-jaw locations. 

Weakened enamel walls are those which through decay, or un- 
necessary cutting, have been robbed of much of their supporting 
dentine. All such unsupported enamel should be cut away Avith a 
chisel, particularly if by any chance the wall of enamel under con- 
sideration will receive much stress in the process of mastication, 
or the introduction of the filling. 

Stress from within should be avoided by not allowing such weak- 
ened walls to remain and form any part of the retention of the 
filling. 

Weakened walls are sometimes allowed to remain, or a portion 
of them, when they can be so protected by a layer of rigid filling 
material as to prevent all stress, but this is permissible only when 
their presence will screen unsightly metal fillings and when the 
kind of filling used can be introduced Avithout injury to the walls. 

Before applying the rubber dam each case should be inspected 
for the surface contact in occlusion and articulation and then the 
margin so laid as to occupy the least exposed position. Many times 
all stress cannot be avoided, but the amount of stress a margin is 
liable to receive should have due consideration and good judgment 
exercised in the placing of the margin. 

38 



RESISTANCE FORM 39 

Resistance Form as Applied to Filling Material. We are forced 
to consider the properties of the filling material to be used in each 
individual cavity. In preparing the cavity we consider the resist- 
ing power of the enamel margin we are able to obtain. We also 
take into account the resistance of the filling material used, to the 
crushing strain, as this property varies greatly. Amalgam, even 
under the most favorable manipulation, is subject to flow and more 
or less spheroiding, which often results in a slight exposure of 
the cavo-surface angle. Again, amalgam is not ductal, hence these 
edges of this filling are easily fractured at the margins under 
stress. This liability to fracture at the margin is also true of our 
cement and silicate fillings and great care should be exercised in 
placing the margins of these fillings. Cohesive gold, especially 
when alloyed with platinum, is our best filling material to resist 
the crushing strain at the margins, and when the edges are not too 
thin, the repeated blows from the opposing teeth only tend to drive 
this material in closer adaptation to the margins. When using the 
gold inlay, it is quite necessary to exercise great care at the mar- 
gins to resist the crushing strain, not of the gold, but of the en- 
amel margin and the intervening cement, for unless the gold in- 
lay fits better than the average gold inlay, there is a line of ce- 
ment which is subsequently^ dissolved. This leaves the last rods at 
the cavo-surface angle unprotected, and very liable to injury. 

It therefore follows that the amount of marginal extension for 
resistance form is less for cohesive gold and gold inlays than other 
fillings. The greater the edge strength of the filling material, the 
more protection it gives the cavity margins. Yet resistance form 
should receive careful consideration with fillings of maximum edge 
streno^th. 



CHAPTER VII. 
RETENTION FORM. 

Definition. Retention form is that part of the procedure in cav- 
ity preparation which deals with the provisions for preventing the 
filing from being displaced by the tipping strain. Force which 
results in tipping the filling bodily from the cavity, is one of the 
greatest enemies to permanency in tooth filling, second only to re- 
current caries. 

Partially Provided For in Resistance Form. Retention form is 
partially provided for in the previous step of resistance form, but 
it is further necessary that provision be made to resist the force of 
mastication in order to prevent the filling as a whole from being 
moved from its seat. 

Maximum Retention Form is required in cavities in the proximal 
surfaces as the missing proximal wall renders these fillings particu- 
larly exposed to injury by the tipping force, during the movements 
of the mandible. 

Flat seats for fillings are imperative in retention form. Seats 
should be cut in a plane at right angles to the stress of mastica- 
tion, which is usually at right angles to the long axis of the tooth. 

The Step as a Part of Retention Form. The addition of the step 
in cavities of Class Two and Class Four is for the purpose of giving 
added retention form. By this procedure in proximal cavities in 
bicuspids and molars, the stress upon buccal and lingual walls of 
the cavity proper is transferred to those portions of the same Avails 
which are a part of the step, a location much better situated to 
withstand the tipping strain. In cavities of Class Four, the addi- 
tion of the step on the incisal or lingual, or both, will give added 
retention form, avoiding heavy cutting at the angle, which weakens 
the remaining tooth substance at the angle, to say nothing of the 
dangers of crossing the retractive tract of the pulp in this location. 

Maximum Retention Form is not required when making simple 
cavities, as they are protected from the dangers of lateral strain 
by the presence of surrounding external walls. This will be found 
to be the case in cavities of Classes One, Three and Five Avhen oc- 
clusion is normal. AYhile in cavities of Classes Two, Four and Six, 
much additional cutting is sometimes necessary to give ample re- 
tention form. 

Acute Angles Required. :\Iuch of the retention form required 

40 



RETENTION FORM 41 

is gained b}^ laying the external surrounding walls at definite angles 
to the seat of the filling. 

Little Retention in Enamel. It should be remembered in this 
step of cavitj^ preparation that there is very little resistance to 
force in a filling wherein retention form is provided for in enamel 
walls. The enamel should be removed to a depth sufficient to get 
anchorage in angles laid in dentine. A good idea of the amount 
of retention form possessed by any completed cavity may be gained 
it one will for the time being imagine that all enamel has been re- 
moved from the tooth. The remaining cavity will still have nearly 
the original amount of retention form. We rely upon the presence 
of enamel in liable areas for resistance to recurrent caries and upon 
sound dentine for retention form. 



CHAPTER VIII. 

CONVENIENCE FORM. 

Definition. Convenience form is that part of cavity preparation 
wherein is made those additional changes necessary for the proper 
placing of a filling. 

Sparingly Used. As these additional cavity changes and their 
accompanying loss of tooth substance are made entirely for the 
conA^enience of the operator they should be resorted to only in cases 
of necessity. 

Maximum Convenience Form. The cutting necessary for con- 
venience form reaches the maximum: first, with inlay fillings, as 
the previously prepared filling is moved to position en masse ; sec- 
ond, in the making of a cohesive gold filling, as it is of value to 
apply force as near as possible at a right angle to the anchorage 
of the first portion of gold, and at an angle of 45 degrees to the 
wall against which the gold is being condensed; third, in cavities 
in the posterior teeth, and in distal cavities as compared with mesial : 
fourth, more is required for proximal fillings not previously sepa- 
rated. 

Minimum Convenience Form is required; first, in usingr plastic 
fillings; second, in anterior oral locations; third, where the teeth 
have had ample separation before the making of a proximal filling. 

The Abuse of Convenience Form is of harm to the teeth and has 
reached its height in a desire to inlay every case possible. When 
excessive cutting for convenience form is necessary to the making 
of an inlay, it would often be better to avoid the unnecessary loss 
of tooth substance by changing the character of the filling. 

Suitable Instruments for various locations in the mouth, par- 
ticularly with the posterior distal cavities, will do much to minimize 
convenience form. 

Previous Separation is the most potent factor of all in lessening 
the amount of cutting for convenience form, the same having been 
considered fully in access form, and should be resorted to in cav- 
ities of Classes Two and Three if for no other reason. 

Starting Points for the making of a cohesive gold filling are a 
part of convenience form and are made by making one of the 
point angles more acute than is required for general retention. 
This is made in the point angle farthest from the hand when the 

42 



CONVENIENCE FORM 43 

same is in position with the plugger point resting in the cavity. 
This will be found to be the point angle farthest from vision and 
most difficult to fill, and from the latter fact should be the first 
filled. 



CHAPTER IX. 

REMOVAL OF REMAINING CARIOUS DENTINE.— FINISHING 
ENAMEL WALLS.— TOILET OF THE CAVITY. 

Removal of Remaining Carious Dentine. 

Definition. This order is the secondary consideration of af- 
fected dentine. In the smaller cavities the previous steps in cav- 
ity preparation will have removed all affected dentine and this step 
has little consequence. However, it is well to have this step come 
to the mind even in these cases so that the minute corners and ob- 
scure localities are not allowed to pass imperfectly prepared. 

In Large Decays the pulp is often in question. The dentine has 
been softened to a near approach to the pulp. If all of this be re- 
moved early in the procedure, the pulp will be exposed to the dam- 
aging effects of air drafts from the chip bloAver, or possibly Ioav 
temperatures in the operating room. Pulps thus exposed not in- 
frequently take on the initial stages of destructive diseases from 
which they never recover, resulting in much pain to the patient 
and chagrin to the operator. The foregoing is particularly true 
when one is making a filling for each of two large proximal cavities. 

Two Large Proximal Cavities. It is often desirable to prepare 
both cavities at the same sitting, particularly when filling witli 
amalgam. 

AVith the cavity first prepared, there might be a long exposure 
of the pulp to a lower than body temperature, if the overlying de- 
cayed dentine is removed at the time the major portion is ex- 
cavated. 

Technic. The remaining decay in this step of procedure should 
be removed with broad spoon excavators, when working on axial 
or pulpal walls. In small cavities where there is no danger of pulp 
exposure the instruments should be small hatchets, with which the 
dento-enamel junction should be examined around the entire cav- 
ity. In case a softened area is found and removed the overlying 
enamel should be chiseled away, thus restoring the correct out- 
line. 

Where Exposed Pulp is expected or pulp treatment is intended, 
the decay is removed just following outline form. 

44 



TOILET OF THE CAVITY 45 

Finishing Enamel Walls. 

Definition. The last cutting done in the preparation of a cavity 
is the finishing of enamel walls. This should always be done with 
the rubber dam in place or at least sufficient means taken to pre- 
vent the margins from again becoming moist. 

No Moisture should be Permitted to come in contact with any 
portion of the cavity surface, after final instrumentation, and if 
by accident any portion should become wet that portion should be 
thoroughly dried and freshened by cutting away the surface, and 
the filling immediately placed. 

The Cavo-surface Angle of the cavity in every part of the cavity 
outline should receive special attention at this step in cavity prep- 
aration. 

The Plane of the Enamel ^vall should be so laid Avith reference 
to the cleavage of the enamel that these will be cut more from the 
outer than the inner ends of the rods, resulting in the last rod at 
the cavo-surface angle being a full length rod, supported by short- 
ened rods. The shortened enamel rods are covered with the fill- 
ing material when the completed filling is in position. 

This is accomplished by a slight planing motion parallel to the 
external enamel line, using a keen-edged chisel or enamel hatchet. 
The gingival margin trimmers are especially adapted for this pur- 
pose when finishing the margins in the gingival third. 

The Marginal Bevel should be laid in a plane at an angle of from 
six to ten centrigrade degrees from the plane of the enamel cleav- 
age. 

The Depth of the Marginal Bevel should generally not include 
more than one-fourth of the enamel wall, but when making a fill- 
ing of inferior edge strength, as amalgam, porcelain, cement, etc., 
it becomes necessary to bury the bevel angle more deeply. 

Locations subject to great stress also require the placing of the 
bevel angle more deeply, even carrying it beyond the enamel and 
laying it in the dentine. 

Toilet of the Cavity. 

Definition. The toilet of the cavity is the final step in the prep- 
aration of the cavity and consists of freeing the cavity of all loose 
particles of tooth substance which are not firmly attached to the 
cavity walls. 

This is best accomplished by a blast of air from the chip blower, 
followed by a thorough sweeping and brushing of all surfaces with 



46 OPERATIVE DENTISTRY 

cotton or spunk held in the pliers, and again using the chip blower 
to remove dust. 

White Enamel Margins indicate the presence of loosened enamel 
rods. If the sweeping does not remove this, the margins should be 
again chiseled, using a keen-edged instrument and a light hand, 
then again be swept with cotton. 

If the whitened margin still persists, it should be brushed over 
with an extra fine cuttle-fish disk or strip when the loosened rods 
will be carried away. The margin should be planed again with 
the chisel. 

Care in the Use of Disk or Strip. It should be fully understood 
that w^hen a disk or strip is used for this purpose, the grit must 
be so fine that there is no considerable cutting done, as there is 
danger of changing the relation of the bevel to .the enamel cleav- 
age. 

All Fluids Should be Used Previous to Cavity Toilet. The habit 
of swabbing out cavities Avith alcohol or other substances after cav- 
ity toilet is useless, and may do harm by introducing substances 
Avith the liquid not easily removed. 

Disinfection and Pulp Protection should have consideration fol- 
loAving the removal of remaining decay and as a preliminary step 
in toilet of the cavity. 

If a fixed oil, or an essential oil Avhich may contain impurities 
has been used, free swabbing and scrubbing of the Avails Avith al- 
cohol, or sulphuric ether, is adA^sed for cleansing purposes, to get 
rid of the oil and other residue. HoAvcA'cr, simply Aviping the caA-- 
ity out Avill not suffice. It must be thoroughly rubbed Avith an al- 
cohol or ether-moistened cotton ball, folloAved by reasonable desic- 
cation from the chip bloAver, and then CA'ery part of the Avails and 
margins gone oA^er and freshly cut. This is the only means of ob- 
taining a clean surface. 

Leaks in Rubber Dam, particularly near the gingival outline, 
must positively be detected. The portion AA'hich has become wet 
should be dried Avith an absorbent and the air blast. Then all parts 
AA^hich have been moistened must be gone over and freshly cut. 
Simply drying such portions is not adequate, as there is left salts 
and albuminoids from the saliva and blood serum Avhich can only 
be remoA^ed by the cutting instruments. The placing of a filling 
OA^er this gummy residue iuA'ites secondary caries. These deposits 
Avill subsequently dissolve out, resulting in a leak. It may be small 



TOILET OF THE CAVITY 47 

but the acid of tooth decay will easily exchange places with such 
films. 

If the cleaning has been fairlj^ well done, it may result only in 
what is termed ''blue margin." 

When time intervenes between cavity preparation and the mak- 
ing of the filling, as from one sitting to another, the walls and mar- 
gins should be retrimmed to give fresh cut surfaces to fill against. 
This is not possible in the making of inlays as to retrim the mar- 
gins destroys the fit. The fact that many times' we cannot place 
the inlays against surfaces which have been freshly cut constitutes 
the greatest enemy to their permanence. 

It is the one great argument that inlays should be made at one 
sitting and under dry conditions. 

Conclusion. All fillings should be made against clean, freshly 
cut walls. 



CHAPTER X. 

MANAGEMENT OF PIT AND FISSURE CAVITIES. 

(CLASS ONE.) 

Location. Class One cavities occur in the occlusal surfaces of 
molars and bicuspids ; in the middle and occlusal thirds of the buc- 
cal and lingual surfaces of molars and in the lingual surfaces of 
incisors, more frequently in the laterals. (See Figs. 1 and 2.) 

The Predisposing Cause of decay in these localities is a fault in 
the enamel due to imperfect closure of the enamel plates, affording 
a convenient point for the lodgment of food particles and the ac- 
tive principles of fermentation which is the exciting cause of all 
tooth decay. 

Extension for Prevention is Seldom Necessary in this class of 
cavities from the fact that the surface of the enamel in the immedi- 
ate neighborhood is exposed to the friction of mastication. It is 
only necessary to cut away the enamel Avails sufficiently to uncover 
the area of affected dentine, and to include in the cavity outline 
all sharp grooves connected with seat of primary decay to a loca- 
tion that will permit a smooth finish to the surface of the filling 
and an outline void of angles. 

Tendency to Extensive Dentinal Decay must be remembered in 
dealing with this class of cavities as the merest opening through 
the enamel will frequently, upon excavation, show an extensive loss 
of dentine. 

Incipient Decays in Occlusal Defects. 

Description. Upon examination it is found that the tine of a 
sharp explorer will pass between the non-united plates of enamel 
to the depth of the entire thickness of enamel in one or more points. 
A more careful examination may show the surface of the dentine 
to be softened to a greater or less extent immediately pulp-wise 
from the enamel fault. Such cases demand immediate attention. 

Outline Form. To open such cavities there is placed in the en- 
gine a discarded No. i/o or 1 round bur which has been made into 
a spade drill by flattening on two sides. This drill is made to 
travel between the plates of the enamel through a major portion 
of the defect, which results in widening the fissure. This prelimi- 
nary step Avill result in much saving of burs, as a bur which has 
been once used on an enamel wall is unfitted to cut dentine. The 

4S 



PIT AND FISSUKE CAVITIES 49 

common practice of using dentate fissure burs for this Avork is con- 
sidered as brutal to the patient and is a thief of the operator's 
time. A No. i/^ or 1 round bur is now used in the engine and ap- 
plied to the dentine. By swaying the hand piece to and fro the 
dentine is cut away from beneath the enamel walls. The bur should 
be frequently removed to allow of cooling as heat readily develops 
and is a great and frequent source of pain to the patient. 

The Use of the Chisel is next advised for the removal of the 
overhanging enamel wall; firs.t, because this is the easiest and 
speediest means of its accomplishment, and second, because this is 
the only means of securing the cleavage of the enamel, giving the 
operator the opportunity to judge the amount of resistance to 
stress in the several localities, and to learn of the direction of the 
enamel rods. Many times a chisel-edged hatchet will be most ad- 
vantageous, one which has a chisel edge upon the sides of the 
blade as well as the cutting edge. The size should be governed by 
the size of the opening secured, but in every case as large an in- 
strument as the orifice will admit should be used. This process 
should be repeated with bur for cutting dentine and chisel or 
hatchet for cleaving enamel until the desired cavity outline is ob- 
tained. 

Resistance Form. The operator should include all fissure and 
sulcate grooves. Cross all grooves and ridges at as near a right 
angle as possible. Avoid eminences of primary calcification. Lay 
the outline as much as possible along the sloping sides of the tri- 
angles and ridges, as these are the most favored localities for a 
cavity margin, for on these sloping surfaces we find the greatest 
amount of friction during the process of mastication, due to the 
excursions of food, and they are the least exposed to direct stress, 
as the blows are of glancing nature. 

Retention Form. Here is a good rule to follow in cavities of 
Class One. When the depth of the cavity is equal to or greater 
than the width, parallel walls are sufficient. But when the width 
exceeds the depth the external walls should meet the internal wall 
at a slightly acute angle. These angles are best made acute by the 
use of a chisel-edged hatchet or hoe, having corners that are slight- 
ly acute. With a planing motion they should be made to travel 
parallel with the base line angles. This will, at the same time, 
flatten the seat or pulpal wall. The extreme ends of long arms in 
a filling, such as results from following a slender fissure, must be 
made retentive. 



50 



OPERATIVE DENTISTRY 



Convenience Form. No convenience form is usuallj" necessary 
in small cavities Class One, except in rare instances it may be of 
advantage to sharpen one of the distant point angles to facilitate 
the starting of a cohesive gold filling. But usually the first por- 
tion of gold may be used of sufficient size to entirely cover the 
pulpal wall, in which case it can be securely locked to position be- 
tween the surrounding avails. 

Removal of Remaining Decay. By this time the carious dentine 




Fig. 17. — Complex Class One cavity prepared. 



will usually have been removed. Should any remain it should be 
excavated with suitable spoons. 

At this point there should be a thorough inspection of the dento- 
enamel junction for small areas of softened dentine which may 
have escaped notice. 

The Walls should all be flat, particularly the pulpal. In cases 
where decay has progressed so deeply into the dentine that to flat- 
ten the pulpal wall would cause the involvement of the recessional 
tracts of the horns of the pulp, the base-line angle should be made 
intermittent, omitting the squaring of the angles in the regions of 
the recessional tracts. 

Disinfection. The cavity should be flooded with alcohol carry- 
ing a small per cent of formaldehyde, say one or one-half per cent, 
and evaporated to dryness. 

Finish of Enamel Walls. The enamel Avail should be planed for 



PIT AND FISSURE CAVITIES 



51 



the entire outline of the cavity with a sharp chisel, using a light 
hand; the desired cavo-surface angle secured, and the bevel angle 
buried to the desired depth. The movement of the chisel should 
parallel the travel of the external enamel line. 

Toilet of the Cavity. The cavity should be swept with a tightly 
rolled cotton ball or piece of spunk in the pliers and the dust finally 
removed with a blast of air from the chip-blower, and the filling 
immediately placed. 




Fig. 18. — Class One filled. Cavity shown in Fig. 17. 

Inlays. If the cavity is to be occupied by an inlay, retention 
form may have been omitted and applied to the cavity just be- 
fore setting the filling, in which case the toilet of the cavity should 
be repeated. If the cavity has already been given retention form 
the same should be temporarily removed while making the model 
by wiping into the retaining angles wax, temporary stopping, or 
cement to be removed before final placing of the filling. 



CHAPTEK XL 

MANAGEMENT OF PIT AND FISSUKE CAVITIES. (CLASS 
ONE CONCLUDED.) 

Large Cavities in Central Fossa of Molars. 

Description. Such cavities are usually the result of knowing 
neglect on the part of the patient. However, in cases where the 
enamel is strong and of a good resistant quality, or the teeth are 
so occluded as to have received little stress, the patient may be in 
ignorance of the great havoc which has been done, due to the 
major portion of the enamel remaining intact. There may exist in 
such cases only the slightest aperture through a defective fissure 
or fault in the enamel. 

Outline Form. This division of Class One should be opened with 
a straight or bin-angle chisel of rather large size to prevent easy 
passage to the sensitive pulpal wall. A chisel of from two to 
three millimeters in Avidth is advised. The securing of adequate 
finger rest on adjacent tissues is important. The chisel should be 
applied so as to throw the chips into the cavity, and the mallet 
substituted for heavy hand pressure. It is best to begin on mar- 
gins most mesial and nearest the operator's eyes, as this increases 
the range of vision to the deeper portions of the cavity at an 
early stage in the procedure. This chipping away of the enamel 
should be continued until enamel supported by sound dentine is 
reached and until the margins have been carried to desired regions 
as set forth in general in the chapter on outline form. 

When Pulp Exposure is Feared. In this case the sixth step in 
cavity preparation will come in third and Ave have for considera- 
tion the removal of remaining decay. 

Up to this point only the most superficial examination of the in- 
ternal surfaces has been made. 

Placing' the Rubber Dam at this point is expedient as dryness is 
imperative. The decay is now removed Avith large spoon excaA^a- 
tors, AA^hose blades are at least tAvo millimeters Avide. These spoons 
AA^hich should be keen of edge are carefully Avorked under the edges 
of the masses of softened dentine and by a prying, SAveeping move- 
ment this lifted en masse from the Avails. The blade of the ex- 
cavator should be prevented from scraping, or sliding over the re- 
gions of suspected exposure. 

52 



PIT AND FISSURE CAVITIES 



53 



When the Pulp is Exposed or nearly so the operator will pro- 
ceed to pulp treatment, of either devitalization or conservation, 
as the case demands. This step completed outline form is again 
taken up and fissures and sulcate grooves included in the cavity 
outline. 

Resistance and Retention Forms. As to resistance, we have only 
to consider the probable stress to be sustained by the filling as 
a whole and of the margins in their various localities. This will 
involve a study of each case in hand, as to occlusion and articula- 
tion, as well as to habits of the patient in mastication. The prob- 
lem of concave pulpal wall is here met in its most exasperating 




A B 

Fig. 19. — I.arge Class One cavities prepared. 

form. Many times if the operator were to take the lower levels 
of the pulpal wall and attempt to flatten and carry this wall lat- 
erally until it could be made to meet surrounding walls at different 
angles, the recessional tracts of the pulp w^ould be crossed and ex- 
posure of that organ result. 

The Flattening of the Pulpal Walls Avoided. (See Fig. 19.) 
This lateral cutting to flatten pulpal walls may be avoided in two 
ways : 

First. The operator may establish a level higher up on the lat- 
eral walls for the creation of the base line angles, resulting in 
steps. These steps should be established in places most remote 



54 



OPERATIVE DENTISTRY 



from recessional tracts, which will generally be found in the neigh- 
borhood of developmental grooves. There should be at least three 
of the steps or small supplemental seats. Four point suspension is 
better. As the seats are small and will probably be required to 
carry relatively Tieavy loads their angles should be most definite. 

Second. To avoid the flattening of these pulpal walls in large 
cavities of this class the operator should build the metal portion 
of the filling immediately into cement which has been applied to 
the pulpal wall. This renders the base of the filling adhesive to its 
seat and nullifies the tendency of the filling to slip or revolve under 
load. 

It might be said here that the principle of the inlay is marginal 




A B 

Fig. 20. — Class One filled. Cavities shown in Fig. 19. 



ridge introduced into a built-in filling, a much valued feature by 
many operators. 

Convenience Form. There is no convenience form required in 
this class of cavities when making a plastic filling. In the making 
of a cohesive gold filling in this division of cavities care must be 
taken that the mesial wall can be reached by direct force from the 
plugger point. In some cases it Avill be required to move the mesial 
margin well upon the mesial marginal ridge to accomplish the de- 
sired result. 

Convenience Point for the beginning of the first pieces of gold 
should be obtained through the use of a small quantity of thin ce- 
ment applied to the deepest portions of the cavity. 

Finish of Enamel Walls and Toilet. The cavity should be phenol- 



PIT AND FISSURE CAVITIES 



55 



ized and the same evaporated to dr^niess. The entire cavity outline 
should be freshly planed, the margins slightly beveled and a posi- 
tively determined cavo-surface angle established. The depth the 
bevel angle is to be buried should be determined. 

The cavity should be thoroughly swept with cotton, the dust dis- 
sipated with a blast from the chip blower and the filling immedi- 
ately placed. 

Pit Cavities in Buccal and Lingual Surfaces of Molars. 

Description. These cavities have their origin in defects in the 
enamel on the buccal surface of lower molars and the lingual sur- 
face of upper molars. 

Instrumentation is the same for the same class and size of cav- 




Fig. 21. — Lingual pit cavities. 

ities just described on the occlusal surface, excepting perhaps it 
may be necessary to use the engine burs in the contra-angle hand 
piece, a necessity seldom met with on the occlusal surfaces. 

Outline Form. The outline should be carried well out of the 
pit or groove and sufficiently extended to meet the general rules 
given in the chapter on this subject. 

Resistance Form will come up for consideration only when the 
outline approaches the occlusal marginal ridge. In such cases if 
the occlusal wall is not made up of a sufficient bulk of dentine to 
withstand the stress of mastication, the outline should be carried 
over the marginal ridge to the occlusal surface, in which case rules 
for the outline of this portion of the cavity will be the same as pre- 
viously given and applicable to all cavities invading occlusal surfaces. 



5G 



OPERATR-E DENTISTRY 



Extension for Prevention will come in for consideration when 
the outline has for other causes been brought near to the free 
margin of the gum. A full application of the rule ''Extension for 
prevention" would demand that the gingival outline be carried 
under the free margin of the gum when the gum has already been 
approached to within one millimeter. A failure to extend the out- 
line is permissible in mouths kept scrupulously clean. 

Retention Form. This step is very simple Avhen the cavity does 
not involve the occlusal surface and is fully obtained when the in- 
ternal line angles have been well squared. However, when the 
cavity reaches the occlusal surface, the filling is subjected to the 
greatest amount of tipping strain in mastication. These will then 




A B 

Fig. 22. — Class One filled. Cavities shown in Fig. 21. 



demand a flat gingival wall, and in some cases of a vital tooth, a 
flat pulpal wall placed parallel to the gingival wall, and the line 
angles surrounding these walls well defined. The four point angles 
should be slightly acute. 

Finish of Enamel Walls. In the management of these axial sur- 
face pit and fissure cavities the varying slant of the enamel rods 
should not be lost sight of. This should be noted when outlining 
the cavity with the chisel. The rods will generally be found to 
incline towards the pit, from every direction close to the defect, 
while a little way out they Avill be found at right angles to the 
surface. 

Goinff farther toward both the occlusal surface and gingival line. 



PIT AND FISSURE CAVITIES 57 

the outer ends of the rods will be found to incline rnore and more 
away from the seat of decay. 

These facts should be borne in mind and a full cleavage ob- 
tained. 

O^here now remains only the usual marginal bevel and cavity 
toilet. 

Pit Cavities in Lingual Surfaces of Upper Incisors. 

Should Receive Early Attention. These cavities should be de- 
tected in their early stages as their near location to the pulp ren- 
ders pulp complications an early sequence. 

It is the best of practice to permanently fill all cases presented 
where faults in enamel are diagnosed. 

Instrumentation. Their location renders excavation hazardous. 
The engine bur should be used for superficial opening only, the 
most of the preparation being done with hand instruments. 

Outline Form. The general rules in outline form should be ob- 
served. Particular note should be made of the extreme incisal in- 
clination of the outer ends of the enamel rods along the margin 
of the incisal wall. 

Inciso-Axial Line Angle. It is generally advisable to allow the 
incisal wall to meet the axial at quite an obtuse angle, in some 
cases almost to the obliteration of this line angle, as the squaring 
of this angle will greatly endanger the pulp. 



CHAPTER XII. 

MANAGEMENT OF PROXIMAL CAVITIES IN BICUSPIDS AND 
MOLARS. (CLASS TWO.) 

Location. Class Two cavities are those whicli originate on the 
proximal surfaces of molars and bicuspids at a point slightly gin- 
gival from the point of contact. 

Predisposing Cause. The predisposing cause is the fact of the 
presence of the adjoining tooth which establishes and maintains 
the sheltered position for the accumulation of substances which un- 
dergo fermentative decomposition. 

Early Detection of These Cavities is Essential. It is of the ut- 
most importance that Class Two cavities be discovered early. More 
pulps are lost to the teeth from the neglect of these cavities than 
from any other cause. Their early detection is by no means an 
easy matter to the inexperienced operator, as often their presence 
IS shown only by a change in the color of the overlying enamel. 

There are yet other cases where the teeth must be separated for 
an examination of the suspected surfaces. 

It requires education in the use of the explorer to detect the dif- 
ference in the ''feel" of the explorer tine in the proximal space 
and the entry of the point into a cavity of slight depth. Wheni 
the decay has extended along the dento-enamel junction the case 
becomes much easier and should never escape the detection of the 
operator. 

Small Proximal Cavities (Class Two). 

Description. By examination there is found to be established 
an area of decay upon the enamel surface between contact point 
and the free margin of the gum, or one or both teeth which go 
to form the space in question. The dentine may or may not be 
involved. The marginal ridge is yet intact and firm. The enamel 
shows no signs of injury in either the buccal or lingual embrasures. 
(Molar, Fig. 3.) 

Gaining Access. Opening the cavity is often the most difficult 
step in the procedure. 

There are three plans of procedure open to the operator. 

The First Method. The one most common and often the best 
is to place the angle of a sharp, straight chisel, say one milli- 
meter in width, on the proximal slope of the marginal ridge and 
tap it lightly with a mallet : turn the other angle so that the chisel 

58 



PROXIMAL CAVITIES IN BICUSPIDS AND MOLARS 59 

edge rests at forty-five degrees to the position of first impact and 
again apply the mallet. Repeat several times and this w^ill gen- 
erally break away the enamel rods in a small V-shaped space. This 
may be continued until the cavity is completely uncovered. In 
comparatively resistant cases the bi-bevel drill may be applied to 
break in the enamel. 

The Second Method of procedure is to use the bi-bevel drill in 
the mesial or distal pit, giving the hand piece that slant which 
will cause the drill to enter the area of decay, when sufficient depth 
has been reached. The chisel is then applied and the occlusal sur- 
face enamel cleaved away either by hand pressure or the mallet. 
This method is more liable to cause pain than the first given and 
should be used with caution. 

The Third Method is to adjust the mechanical separator and at- 
tack the enamel with a sDiall chisel from the buccal direction, grad- 
ually shifting more and more to the occlusal surface until finally 
the enamel ridge gives way to the force of the chisel. 

Preliminary Separation should in most cases be resorted to for 
proper access for the many reasons set forth in Chapter IV. 

This is Best Accomplished by packing the cavity at this stage 
with gutta-percha for a few days or weeks. When case returns we 
should be ready to consider outline form. 

Outline Form. Outline form in Class Two involves the outlin- 
ing of the cavity proper, as well as the outlining of the occlusal 
step which is generally necessary because of the more secure seat- 
ing and rigidity it gives a filling in all proximo-occlusal cavities in 
molars and bicuspids when the marginal ridge has been broken. 

Step May be Omitted. First: In cases Avhich are to remain 
permanently disarticulated, as when opposing tooth has been lost. 

Second: When the proximating tooth is to be absent permanently 
thus obviating much cutting buccally and lingually in extension 
for prevention, as the remaining walls are sometimes strong enough 
to give sufficient resistance form without the added step. 

Third: In proximal decays in the gingival third following ex- 
cessive gum recession (so-called senile decay). 

Fourth: When for any reason the patient should be shielded from 
long operations, or the life expectancy of either the patient or the 
individual tooth is short. 

Fifth: 111 that form of lower bicuspids with a well defined and 
perfect transverse ridge. (Fig. 23.) 

Outline of Cavity Proper. The outline should be carried into 



60 



OPERATIVE DENTISTRY 



both buccal and lingual embrasures until the excursions of food 
througli these embrasures will sweep the margins of the completed 
filling for its entire length. This extension Avill result in carrying 
the outline out sufficiently that it can be seen to pass imder the gum 
in full view. 

A Good Rule to Follow is to cut sufficiently that a chisel one 
millimeter in width will pass easily from the embrasures to the 
open cavity when dragging the cutting edge lightly over the free 
margin of the gum. This is stated as a general rule only, there 
being circumstances which would permit falling short of this amount 
of space and yet there are cases which demand a greater amount 
of cutting to fully meet the requirements of extension for preven- 
tion, due to oral conditions and dental irregularities. 




A B 

Fig. 23. — One of the few cases in which the step may be omitted in Class Two cavities. 



Extensions Gingivally. The cavity outline should be carried sub- 
gingivally in extension for prevention when from other reasons 
that part of the outline approaches to within one millimeter of the 
gum line. The application of this rule will invariably cause the 
outline to go beneath the gum in case the gum is in or resumes its 
normal position. 

If there is reason to believe that it will return to its normal 
position this fact should be considered. In cases of permanent re- 
cession it is better to stop the cavity outline midway from contact 
to gum line. 

Care at Axio-Gingival Angles. The buccal and lingual portions 
of the outline should be carried directly gingivally and be made 



PROXIMAL CAVITIES IN BICUSPIDS AND MOLARS 61 

to join the gingival portion of the outline by the use of a seg- 
ment of a small circle. The use of a large circle here is a most 
common error. Investigation of fillings Avill show many failures 
wherein a large circle has been used allowing the external outline 
to disappear in the proximal space before it has disappeared be- 
neath the gum. 

The Gingival Outline should be a straight outline except in well 
defined and high gum festoons, when it may be made convex to the 
occlusal surface. 

Forming the Step. Place a small round bur or spade drill against 
the axial wall at the dento-enamel junction, immediately below 
the central fissure and undermine the enamel the desired distance 
in the direction of the central axial line of the tooth. Here apply 
all of the rules and methods of procedure given in the formation 




A B 

Fig. 24. — Class Two cavities in molar and bicuspid suitable for cohesive gold or amalgam. 

of a simple occlusal cavity. Also remember to apply the rules as 
given in outline form, particularly as to resistance form. 

Area Included. In addition to the above it is a safe rule to state 
that the step portion should involve the central third of the oc- 
clusal surface bucco-lingually. 

Avoid all Angles in outline. Care should be taken when us- 
ing the step that its union with the cavity proper does not show 
in the outline by an angle at their junction. Also when not us- 
ing the step, as in the few cases cited, care should be given not to 
allow the axio-buccal and axio-lingual line angles to meet the ex- 
ternal enamel line. These line angles should be stopped before 
they approach the enamel wall. 



62 



OPERATIVE DENTISTRY 



Resistance and Retention Forms. To reach the maxinium of 
these forms it is necessary that the gingival ivall be flat and laid 
in a plane at right angles to the stress of mastication. The gingival 
Avail should meet the axial wall at an angle slightly acute. 

The grooving of the gingival wall is condemned. 

The Buccal and Lingual Walls should be flat, parallel, meet the 
gingival wall at least at right angles, and meet the axial wall at 
definite and acute angles. 

The Axial Wall should be convex to the proximal and meet the 
pulpal wall in a rounded pulpo-axial line angle. 

The Pulpal Wall should be laid parallel to the same plane as 
the gingival wall and slightly broader at the portion most dis- 
tant from the cavity proper. This gives a pulpo-distal or pulpo- 




A B 

Fig. 25.— Class Two filled. Cavities shown in Fig. 24. 



mesial line angle of a little greater length than that of the pulpo- 
axial line angle, resulting in a dovetailed effect that is most ef- 
ficient. 

Line Angles. The line angles should be squared out and made 
definite by the use of small hatchets and hoes of suitable shapes 
to reach the desired localities. 

The gingivo-buccal and gingivo-lingual line angles should ex- 
tend from their corresponding point angles to the dento-enamel 
junction. The axio-buccal and axio-lingual line angles which arise 
in the same point angles should travel occlusally one-third to one- 
half the height of the axial wall. In some rare cases where the 
pulpal wall is low from decay these line angles may meet the axio- 



PROXIMAL CAVITIES IN BICUSPIDS AND MOLARS 63 

pulpal line angle. A failure to observe this rule endangers the 
pulp through a liability of crossing its recessional tracts. 

Convenience Form. In the making of a cohesive gold filling a 
convenience point for the retention of the first piece of gold is 
desirable. This is best accomplished by employing a small in- 
verted cone bur, say number thirty-three and one-half. 

The flat face is placed on the gingival wall and first sunk to one- 
third its depth then drawn for a short distance occlusally along 
the axial line angle, taking dentine slightly at the expense of both 
axial and external walls. 



A B 

Fig. 26.-^Fillings shown in Fig. 25 contacted, illustrating the marble contact. 

With the making of a plastic filling there is no need of cutting 
for convenience form in this cavity. 

Inlays. When using an inlay proper convenience form is ob- 
tained by thorough separation and causing the external walls of 
both step and cavity proper to meet the gingival and pulpal wall 
at slightly obtuse angles. This will give draw to the occlusal. 

Finish of Enamel Walls. The enamel Avails are planed to full 
cleavage and the margins arc slightly beveled. All but the gingival 
margins may be done Avith the chisel. Special instruments are re- 
quired to bevel the gingival cavo-surface angle, known as gingival 
marginal trimmers. These are made rights and lefts for mesial 
cavities, and rights and lefts for distal cavities and should be on 



64 OPERATR-E DENTISTRY 

hand in two sizes, which would result in eight instruments in a 
good working set. 

In planing the gingival enamel wall the operator should have 
in mind the gingival inclination of the enamel rods in this locality. 

Toilet of the Cavity should now be made and the filling immedi- 
ately placed. 




CHAPTER XIII. 

LARGE PEOXIMAL CAVITIES ENDANGERING THE PULP. 
(CLASS TWO, CONTINUED.) 

Description. This class of cavities when presented show exten- 
sive loss of dentine in the proximal wall. The marginal ridge may 
be standing or it may have been broken through stress of mastica- 
tion. In some cases there may be an occlusal decay in the central 
fossa. 

Danger of Pulp Exposure. There is always great danger of pulp 
exposure in these cases and this fact must be continually borne in 
mind, during the procedure of preparation. The liability is in- 
creased when the patient is young or the cusps of the tooth are 
high, particularly when there exists a deep pit cavity in the oc- 
clusal surface necessitating a low pulpal Avail. With young pa- 
tients the pulps are large and the horns of the pulp generally ex- 
tend well toward the cusps. Teeth with high, prominent cusps us- 
ually have long pulp horns, which should be considered in making 
resistance, retention and convenience forms. 

Outline Form. The first cuts in this class of cavities should be 
with the chisel, using hand pressure, being sure that adequate hand 
and finger guard has been obtained. This precaution is essential 
as the chisel must be prevented from reaching the sensitive soft- 
ened dentine within the cavity. Place the chisel so as to throw 
the chips into the cavity. The chisel should be made to engage 
only a small portion of enamel at each cut. Should the enamel 
prove resistant the aid of the mallet may be resorted to, still main- 
taining a firm finger rest. 

Extension for Prevention is frequently not necessary as the ex- 
tension necessarj^ for proper resistance form will carry the cavity • 
the required distance into both buccal and lingual embrasures. 
However, in many cases the decay will be found to have progressed 
more toAvard one embrasure than the other AA^hich necessitates ad- 
ditional cutting for prevention, in the direction of the embrasure 
least approached by decay. This should be done to the fulfillment 
of the rule for '^extension for prcA^ention. " 

Gingival Outline. The gingival outline in these cases Avill gen- 
erally be under the free margin of the gum. At this stage it should 
be planed Avith the enamel hatchets until the OA^erhanging enamel 

65 



66 OPERATIVE DENTISTRY 

is broken away to give access form for the free passage of the dam 
and ligature, vv^hich should noAV be placed and the cavity super- 
ficially sterilized. 

Occlusal Outline. When the cavity has been rendered dry the 
occlusal outline should be proceeded with. This is carried out as 
previously given in the forming of the step portion, and the full 
satisfaction of the rules given in Outline Form, Chapter V. 

Removal of Remaining Decay. This is an instance where the 
sixth step in cavity preparation comes in third and should now 
be cautiously proceeded with. 

Technic. Large spoons should be used. The softened and dis- 
colored dentine should be lifted from its position with as little pres- 
sure pulp-wise as possible. If exposure exists upon its removal, pulp 
treatment for devitalization and removal is the immediate pro- 
cedure. If exposure does not exist and the operator has reason 
to believe that that organ is healthy the pulpal and axial walls 
should be lightly scraped with large spoon excavators, the Avails 
disinfected with the favorite drug, then dried, phenolized and dried 
again, the latter precaution to prevent thermal shock to the pulp 
during the remaining portion of cavity preparation, the impera- 
tive necessity for which is shown when pain is induced by a blast 
of air from the chip blower. 

Resistance and Retention Forms. When the central portion of 
the decay is found to be deep and no exposure exists, the pulpal 
and axial walls should be left in their central portions much as de- 
cay has left them, no attempt being made to flatten these Avails on 
a plane of their greatest depth as pulp exposure may result. The 
line angles surrounding these tAvo Avails should be established on 
higher levels. 

The Gingival Wall should be made flat in every direction. This 
, is accomplished by lowering the point angles root-Avise to the IcA-el 
of the central portion. 

Convenience Form. Every part of the cavity should be exam- 
ined to see that it is accessible to direct force in the packing of 
the fllling and a coiwenience point cut in each of the gingivo-axio- 
lingual and gingivo-axio-buccal point angles. 

Pulp Protection. The caAdty should be flooded Avith an efficient 
non-irritating disinfectant, dried, phenolized and again dried. If 
the pulp is in danger it should be protected as described in Chap- 
ter XXXIV. 



LARGE PROXIMAL CAVITIES ENDANGERING PULP 



67 



Finish of Enamel Walls. 

The enamel Avails should now be inspected, corrected for com- 
plete cleavage and the proper cavo-surface angle established, us- 




Fig. 27. — Large Class Two cavities in non-vital teeth restoring part of the occlusal surface for 
the protection of weakened walls. 




A B 

Fig. 28. — Class Two filled. Cavities shown in Fig. 27. 



ing for this a keen-edged chisel and a light hand with a planing 
motion parallel with the external enamel line. 

For Toilet of the Cavity nse a few blasts of air from the chip 



C8 



OPERATIVE DENTISTRY 



blower, followed Avith a thorough brushing with a ball of cotton 
and more air blasts. The filling should be immediately placed. 

Large Proximal Cavities in Non- Vital Teeth. 

In the management of this class of cavities, cutting for resistance 




i 



A B 

Fig. 29. — Mesio-occluso-distal (M.O.D.) cavities in molar and bicuspid, vital teeth. Note 
that the occlusal portion of the cavities does not show any retentive form. It is not necessary 
to undercut these walls as there is ample retention in other parts of the cavity. 




A B 

Fig. 30. — ^lesio-occluso-distal fillings. Cavities shown in Fig. 29. 

to stress reaches the maximum and outline is many times materially 
extended for this purpose alone. 

Outline Form, With Molars. All decay and softened dentine is 
removed. Often this will leave standing an entire cusp of un- 



LARGE PROXIMAL CAVITIES ENDANGERING PULP 



69 



supported enamel and possibly both proximal cusps are thus un- 
supported. In such cases a thin-edged carborundum wheel is placed 
on the occlusal and this surface ground away for one or two milli- 
meters, extending as far toward the central axial line to just be- 




Fig. 31. — (A) First superior molar, non-vital, restoring the lingual cusps. (B) Second superior 
bicuspid, non-vital, restoring the entire occlusal surface. 




A B 

Fig. 32. — Class Two filled. Cavities shown in Fig. 31. 

yond the buccal or lingual groove, or both when both cusps are to 
be removed. This grinding process is carried to a greater depth 
in the region of the groove, resulting in a step which gives the fill- 
ing an occlusal surface seating. 



70 OPERATI\'E DENTISTRY 

With Bicuspids this buccal or lingual outline is carried past the 
crest of the cusp involved and partiall}^ down the opposite slope. 
This procedure results in disarticulating the frail enamel wall and 
so placing the metal that it will receive the force of mastication. 

In Mesio-Disto-Occlusal Cavities in both bicuspids and molars, 
which are vital, and when using cohesive gold as a filling, the occlusal 
outline should include all of the middle third bucco-lingually. It 
should be made sufficiently deep to remove all of the enamel in the 
central fissure. 

For cohesive gold the buccal and lingual walls should be parallel 
.and without retention as the retentive form should all be placed low 
in the gingival angles of both mesial and distal cavities. 

In the use of amalgam the outline should be farther extended buc- 
co-lingually, to include about one-half of each of the buccal and lin- 
gual thirds. Thus two-thirds of the occlusal surface bucco-lingually 
will be filling. This occlusal portion should be without retentive 
form with the buccal and lingual walls meeting the pulpal wall at 
angles slightly obtuse. This is the minimum amount of extension 
for favorable vital cases. 

In Cases of Extreme Frailty the entire occlusal surface of molars 
and bicuspids should be replaced with filling of at least one milli- 
meter in thickness. With upper molars and bicuspids, when non- 
vital and very frail mesio-occluso-distal cavities, the lingual cusps 
should be removed for one or two millimeters and replaced with 
filling material. 

Retention Form is Completed by squaring up the side walls and 
sub-pulpal wall, making a box shape of the pulp chamber, with 
fairly definite point angles. 

Convenience Form. No convenience form is necessary in this 
class of cavities, except for inlay fillings, which will be considered 
later. 

Neglected Access Form. In cases where large proximal cavities 
are of long standing and there has been much tipping to the prox- 
imal of one or both teeth, preliminary separation for good access 
is essential. Without this preliminary step complete contour res- 
toration and proper contact is impossible. This is particularly true 
when the cavity is in the mesial of the first molar. ^lany times 
the second bicuspid will seem to have been engulfed within the 
molar cavity. In cases where preliminary separation for obvious 
reasons is impossible, the evil may be partly overcome by the free 
cutting awav of both buccal and lingual Avails until the filling may 



LARGE PROXIMAL CAVITIES ENDANGERING PULP 71 

be built in with a proximal surface slightly convex to the prox- 
imal. However, this is but a makeshift of a filling and the result- 
ing proximal space will always be defective. 

Toilet of the Cavity. In large decays, particularly if the pulp 
has been removed, there is more or less danger in leaving coatings 
of various materials clinging to the walls. Care should be taken 
that the walls are scrupulously clean. It is an advantage if the 
cavity be scrubbed with solvents for the suspected coatings. The 
cavitj^ should then be dried, the enamel walls planed and the cav- 
ity freed of all debris. 

Over-desiccation. Particular care should be had not to use ex- 
cess desiccation in pulpless teeth as this will render them brittle 
and easy of fracture when put to use. 



CHAPTER XIV. 

MANAGEMENT OF PROXIMAL CAVITIES IN INCISORS AND 

CUSPir)S NOT INVOLVING THE ANGLE. (CLASS 

THREE.) 

Definition. Class Three cavities are those in the proximal of 
incisors and cuspids where it is not necessary to restore the incisal 
angle. The angle may be allowed to remain when the enamel at 
the angle is supported by sound dentine to an extent which will 
give it sufficient resistance to prevent fracture under stress of 
mastication. 

General Form of Class Three. Cavities in incisor proximal sur- 
faces differ from all others in that they are in the surface of teeth 
of a triangular form and the cavities of necessity must be of this 
form, rather than the typical box shape in the other classes of 
cavities. 

Location of Primary Decay. The location of primary decay, as 
with all contact decay, is just gingivally from contact point. This 
will result, as a rule, in the seat of initial decay being about mid- 
way from the incisal edge to the gingival outline. As the plates 
of enamel, both labial and lingual, are quite heavy and usually 
removed from direct stress, there will generally be considerable 
loss of dentine while the enamel walls are yet intact. The decay 
may be apparently small, yet reflected light by the use of mouth 
mirror will show a discoloration of a well defined area. The 
curved tine of an explorer may or may not enter from either the 
labial or lingual embrasure. 

Opening the Cavity. Bathe the surfaces of all the anterior teeth 
in that jaw with water to free them of micro-organisms and gummy 
material, particularly the gingival border, and apply the mechan- 
ical separator. 

Gaining Access. With a small straight chisel of about one milli- 
meter in width cut away the enamel edge, throwing the chips into 
the cavity. Adequate finger rest must be secured before applying 
the chisel and onh^ small portions of enamel engaged at each ap- 
plication, as a failure in either respect may result in checking the 
.enamel to a greater extent than desired. When sufficient entrance 
has been made to the cavity to admit the instrument, the remain- 
ing enamel margins may be planed from this direction until a liga- 

72 



PROXIMAL CAVITIES IN INCISORS AND CUSPIDS 73 

ture will pass from the incisal to the gingival line. Where time 
will permit the case should be packed for preliminary separation 
as described in Chapter IV. If immediate separation and filling is 
to be practiced the rubber dam should be adjusted and the me- 
chanical separator placed and tightened to a snug pressure. The 
separator should be tightened from time to time until the required 
separation is obtained. The approximate space required is from 
one-half to one millimeter where only one cavity exists in the prox- 
imal, and a full millimeter in cases where tAvo cavities exist. 

Outline Form. As these cavities are located in the most exposed 
portion of the mouth esthetic reasons demand as little cutting as 
possible consistent with the demands for permanency. However, 




ABC 

Fig. 33. — Class Three cavities filled so that the entire cavity outline, excepting that por- 
tion covered by gum tissue, is in full view of the operator. The gingival portion of {B) has 
been cut sufficiently low to be covered by gum tissue. 

it is a good rule, in outlining cavities of Class Three, to extend in 
all directions until when the filling is completed, the entire cavity 
outline not covered with gum tissue, is in full view of the operator. 
(Fig. 33.) As stated before, excessive cutting to obtain this con- 
dition may be obviated by proper separation. 

The Gingival Outline should be carried midAvay between con- 
tact and gum line, and farther extended to go under the gum when 
it approaches to within one millimeter of the gum. Great care 
should be exercised to square out both labial and lingual axio- 
gingival angles, carrying them sufficiently into these embrasures 



74 OPERATIVE DENTISTRY 

that the cavity margins may be in full view as they pass under the 
gum. 

The Incisal Outline should be carried incisally until the margin 
of the filling will be permanently in view, with a space sufficient 
to admit of the free use of the tooth brush on the margin. This 
would, in many instances, carry the margin beyond the incisal 
edge and make a Class Four cavity and is only avoided by separa- 
tion and filling of the cavity to a slightly excess contour. 

The Labial Outline should be carried into the labial embrasure 
until the margins are in full view. The enamel should be split 
away until full length rods are obtained. On account of the ex- 
posed location of these cavities the esthetic reasons demand as lit- 
tle cutting labially as possible. As this margin is practically re- 
moved from the stress of occlusion it is not essential that the enamel 
be supported by dentine in every instance. However, care should 
be taken that the rods are full length and that all rods are re- 
moved where there has been a backward decay as sho^^ni by a 
whitened powder-like condition at their dentinal ends. 

Additional Extension for esthetic reasons is sometimes required 
in thfe labial embrasure. This is more often true in the mesial cavi- 
ties wherein the teeth are angular in form and present surfaces 
that are quite flat, resulting in a very square or prominent mesio- 
labial angle. In such cases the outline should be carried over the 
angle and into the labial surface, that the metal may be brought 
into the light, otherwise the completed filling will have the appear- 
ance of a decay or dark spot on the tooth. 

The Lingual Outline must be carried into the lingual embrasure 
sufficiently to be brought into full view in all cases. 

In the case of teeth of rounded form this will not always in- 
clude the proximal marginal ridge. In teeth of a squared form 
and prominent lingual ridges the marginal ridges should be in- 
cluded and the outline carried along the axial slope of the ridge. 
The fact that many cases show a lingual articulation and occlusion 
on the lingual marginal ridges of upper incisors, will bring de- 
mands for including within the cavity the major portion of these 
ridges, unless supported by a good bulk of sound dentine. The 
failure to recognize this fact on the part of many operators is re- 
sponsible for the loss of a large per cent of this class of fillings. 

Resistance Form. No special resistance form other than that 
just given is required in this class of cavities. 

Retention Form. When this order in the preparation has been 
reached attention should be directed to the incisal angle, particu- 



PROXIMAL CAVITIES IN INCISORS AND CUSPIDS 



75 



larly in the larger cavities, as cases will be met in which it will 
be found necessary to remove the incisal angle to secure proper 
^'retention form." This looking to the incisal first will decide 
this point early in the procedure. 

The Incisal Line Angle should meet the axial wall at least at 
a right angle. In cases where this line angle is short, as found in 
shallow cavities, the incisal line angle should meet the axial wall 
at a slightly acute angle. It is not necessary to make a convenience 
angle at the incisal point angle. (Fig. 34.) 

The bevel angle on the gingival wall becomes the fulcrum. It 
is only necessary that the distance from this point to the incisal 
point angle be greater than that from the same point on the gin- 



r^ 


"1 


J^^TT^ 


1 


m A ' 


A 




J 



Fig. 34. — Drawing to illustrate the retention at the incisal angle of Class Three cavity. 
In shallow cavities with a short incisal line angle as d — b, the angle at b should be acute. 
In deeper cavities and longer incisal line angles as the one shown at d — c, the incisal point 
angle is efficient if it is a right angle and may even be obtuse. In the illustration shown 
the filling would pivot to exit at a. Dotted lines a — b and a — c are the same length hence 
the point angles of the two fillings would describe an arc of the same circle in tipping to exit. 

gival wall to the most external portion of the incisal line angle. 
The more shallow the cavity in Class Three the more acute must 
be the incisal point angle. 

Other Point Angles. The gingivo-axio-labial and the gingivo- 
axio-lingual point angles are now carried into the dentine at the 
expense of both axial and external walls, care being given not to 
groove the gingival wall. 

Line Angles. Line angles are made with small hatchets and hoes 
of suitable sizes, say, one-third to one-half millimeter in width, with 
edges that are keen and whose corners are well defined, not having 
been rounded through careless sharpening or wear. 



76 



operati^t: dentistry 



The Axio-Labial Line Angle is chased and sharpened for its entire 
length, making it particularly definite as it approaches each of the 
point angles. 

The Axio-Lingual Line Angle is made definite for one millimeter 
in each direction from its t^vo point angles, omitting the central por- 




Fig. 35. — Class Three cavities prepared for cohesive gold. While the cavity in the cuspid 
(A) restores the mesial angle the shape of these cavities and the rules governing their man- 
agement places them in Class Three. 




ABC 
Fig. 36. — Class Three filled. Ca\ities shown in Fig. 35. 



tion, as this precaution will give added resistance form to the lingual 
wall. The sharpening of these line angles is best accomplished by 
engaging the instrument in the dentine the desired distance from 
the point angle and cutting to the angle. 

The Gingivo-Axial Line Angle should be well defined to make the 



PROXIMAL CAVITIES IN INCISORS AND CUSPIDS 77 

gingival wall meet the axial at a definite angle, but should in no way 
be a ditch or groove. 

The Gingivo-Labial and Gingivo-Lingnal Line Angles should be 
cut away from their point angles out to and end at the dento-enamel 
junction. As the general form of the cavity is that of a triangle 
these angles will always be acute. 

Gingival Wall. The gingival wall should be flat in every direc- 
tion. 

Axial Wall. The axial wall should be left as decay has left it in 
the central portion and all additional cutting should tend to make it 
take on the form, in miniature, of the surface of the tooth in which 
the decay has originated. A disregard of this rule will endanger 
the pulp, whereas if the axial wall is left as convex as possible the 
pulp has all possible protection. 

Labial and Lingual Walls. These Avails should be, as far as pos- 
sible, of the same thickness for their entire length, which will re- 
sult in their inner surfaces being of the same contour as the ex- 
ternal surface of the tooth. 

Convenience Form. Taao convenience points are advisable in this 
class of cavities, cut in each of the gingivo-axio-labial and the gin- 
givo-axio-lingual angles. The filling should be begun in the latter 
angle. 

Removal of Remaining Decay. At this point inspect the dento- 
enamel junction for softened dentine. Also the entire axial wall 
should be scraped with large spoons for the removal of the last of 
the softened dentine, the cavity disinfected, dried, phenolized and 
again dried. Pulp protector should be applied when indicated. 

Finish of Enamel Walls. The enamel walls should be planed to 
full cleavage, with suitable instruments of chisel edges, not forget- 
ting the incisal and gingival inclination of the rods of these loca- 
tions. Bevel the cavo-surface angle, give the cavity its toilet and 
immediately place the filling. 

In Non- Vital Cases. When the axial wall has been lost by reason 
of pulp removal the entire pulp chamber should be filled with ce- 
ment of a very light yellow color or even a white cement may be 
used. In extremely frail teeth this may be only partially filled and 
the remaining portion used for retention. 



CHAPTEE XV. 

MANAGEMENT OF PEOXIMAL CAVITIES IN INCISORS IN- 
VOLVING THE ANGLE. (CLASS FOUR.) 

Definition. Cavities of Class Four are those in which the incisal 
angle has either been lost or can not be safely retained. The deci- 
sion as to its restoration is of most vital importance. To cut the 
angle from nearly every incisor which has a proximal decay is little 
short of malpractice, while at the same time to attempt to save those 
not wholly and adequately supported by dentine is to invite many 
disastrous failures. 

Conditions Demanding Frequent Angle Restoration. First. When 
contact is in the incisal third. In such cases a very small decay will 
involve all of the dentine toward the incisal angle. 

Second. Incisors which have long flat proximal surfaces. Such 
teeth will show a line of decay extending gingivo-incisally and may 
entirely weaken the incisal angle before the pulp is in danger. 

Third. The pulp may be involved and its removal materially 
lessens the resistance of supporting dentine at the angle. 

Four til. The angle under consideration may be so located that it 
is frequently required to stand great stress in service. This is a 
point which must not be overlooked as an angle which stands Avell 
exposed must bear much greater and more often repeated force than 
an angle which does not occlude or can not be brought into articula- 
tion. 

Difference Between Mesial and Distal Surfaces. The above four 
conditions will be more frequently met Avith in mesial surfaces, 
hence the mesial angles are in greater danger and more often re- 
quire restoration. 

Plans of Angle Restoration. There are four general plans of re- 
storing the incisal angle which are worthy of consideration. Many 
plans have been advanced from time to time, but the four given 
below seem to haA^e remained in favor. 

Retention Form in Class Four Fillings. With each of the plans 
presented and generally practiced the effort is made to remove or 
nullify the principle of the lever. 

With proximal fillings wherein the force of mastication is brought 
in direct contact Avith the filling the principles of the leA'er must be 
reckoned Avith. The force of mastication is the poAver, the filling the 
lever, the anchorage in the point angles the load and the point on 



PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE 



79 



which the filling would most likely pivot to exit the fulcrum. By a 
study of the case we find we must deal with the force of levers of 
both the first and second class. 

In Fig. 37 we have an illustration of a Class Four, plan one filling 
wherein the principles of a lever of the second class are fully opera- 
tive. The heavy long lines a-h represent the full length of the 
lever. The short heavy lines a-c represent that part of the lever 
which is the working arm, as the load is at c. That we may study 
the amount of anchorage to be provided for at the incisal angle, (c), 
we will ignore the assistance of the two gingival point angles and 
for that reason they have not been shown in the drawing. We here 




Fig. 37. — Drawings to illustrate the principle of the lever in the dislodgement of fillings of the 

fourth class, plan one. 



have a lever of the second class with the fulcrum at a, the load at 
c and the force at h. 

In order that we may not inject into the problem at this time the 
principle of the bent lever we will consider that by the lateral move- 
ment of the mandible the force is applied at right angles to the 
*' lever-arm." In diagram A, Fig. 37, the working arm is one-half 
of the lever which is of the second class. We then have the follow- 
ing with X representing the load, or unknown quantity : 

100 lbs. : X : : 2 : 4 = ^^ = 200 lbs. ==: x. 
2x 

It would therefore follow that an incisal point angle placed mid- 



80 



OPERATIVE DENTISTRY 



way between the gingival wall and the incisal surface of the filling 
w^ould be required to stand a strain just double the force at the in- 
cisal, or place of impact. In diagram B, Fig. 37, the incisal point 
angle is placed three-fourths of the way from the gingival to the in- 
cisal and we then have : 

400 
100 lbs. : X : : 3 : 4 r= -^^ = 1331^ lbs. = x. 

This shows a strain on the incisal point angle of one hundred and 
thirty-three pounds. It will therefore be seen that the incisal point 




Vis- 38. — Drawings to illustrate the principle of the lever in the dislodgement of tillings of the 
fourth class, plans one and two. 

angle should be laid as close to the incisal edge of the tooth as the 
strength of the dentine protecting that angle will permit as it fol- 
lows that: ''Tlic farther ilie incisal angle is from ilie force of masti- 
cation tlie greater will he tlie strain on hotli dentine and filling at 
iliis angle.' ^ 

With Fig. 38 we will consider the principles in a little more com- 
plicated form. Let a represent the fulcrum, h and c the loads and d 
the point of the application of the force. The radii of the arcs of 
the circles represent a few of the directions from which force may 
be received by the filling. 



With the lidit lines the force Avould be 



PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE 81 

absorbed b}' the Avails of the cavity. Force from the direction of the 
dark lines would put into operation the principles of the lever. 

In diagram A, Fig 38, the filling would operate as a lever of the 
second class upon the load at c, as described in Fig. 37. "With the 
gingival point angles at h the filling would operate as a lever of the 
first class over the same fulcrum (a), provided the gingival outline 
or fulcrum has been laid higher than the point angle and therefore 
nearer the point of the application of the force. 

In case the gingival margin has been laid lower than the point 
angle or farther from the point of impact than the fulcrum we have 
a lever of the second class which when figured out will draw an im- 
mense load as shown in the explanation of Fig. 37. 

In case the gingival point augles are cut more root-wise than the 
gingival margin and we have a lever of the first class we must con- 
sider the principles of the bent IcA'er. When the direction of the 
force (or of the resistance) is not at right angles to the arm or the 
lever on which it acts, the ''lever-arm" is the length of the per- 
pendicular from the fulcrum to the line of the direction of the force 
(or the resistance). 

We must therefore conclude : First, that gingival point angles 
should be placed so as to extend more root-wise than the height of 
the gingival line at the proximal (that part of the gingival wall 
which is nearest the incisal is regarded as the highest point). 
Second, the farther the gingival wall with all its parts is from the 
incisal the greater will be the length of the poAver arm Avith each 
individual" 1)1oav. Third, the nearer the gingival Avail is to the incisal 
the less the number of directions from AA^hich force may be received 
Avhich Avill act upon the filling as a lever. 

In order that Ave may eliminate the principles of the IcA^ers, the 
step caA^ty, in classes tAvo and four, has been dcAdsed as shoAvn in 
diagram B, Fig. 38. It Avill be seen by the radii of the three arcs 
draAvn that the increase of the surface of the filling exposed to 
force does not increase the dangers of the IcA^er as the area of the 
seat of the filling has also been increased AA'hich Avill absorb the force 
beneath the increased surface. Again, so long as the incisal angle 
in the step (at c) holds and the filling material remains rigid the 
lever principle has been eliminated as regards all other anchorage 
of the filling. 

Direction of the Incisal Angle. Fig. 39 is a draAving to illustrate 
the difference in the directions the point angles take in tipping to 
exit Avith A'arious filling. Let the perpendicular shaft represent the 
varying length of Class Four fillings and the horizontal bars the 



82 



OPERATIVE DENTISTRY 



varying lengths of the step in plan two of this class. The dotted 
lines are the radii of the various circles the arcs of which the point 
angles would describe in moving to exit, pivoting on the gingival 
margin. The length of the step portion relative to the height of 
the filling determines the direction the incisal point angle must take 
to exit. With a short proximal portion and a comparatively long 
step portion, the first movement of the point angle is almost per- 
pendicular. See fillings in Fig. 39 {a, x, li; also g, f, n). 




/- 



.. ^^ ^ " — " " 



01 



Fig 39.— Drawing to illustrate the difference in the directions the point angle fillings take in 
tipping to exit with various fillings. 

Note the difference in the direction the point angle Avould take 
to exit with an increased length of filling inciso-gingivally. Also 
see li, X, a, and then li, x, h, and on down until it is 7i, x, g. It will 
be seen that there is a gradation toward the horizontal movement 
of the incisal point angle to exit. Again note the change of direc- 
tion to exit of the incisal point angles in g, a, i, and then g, I, j, then 
g, c, A', and on down to g, f, n. We see in this series that there is a 
gradation toward the perpendicular movement of the incisal point 



PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE 83 

angle to exit. In the first instance we lengthened the axial wall, us- 
ing the same length of step. In the second instance we shortened 
the axial wall and at the same time lengthened the step and the 
change is more rapid. It would seem then that the direction to be 
given the incisal point angle is determined by the degree of the 
circle in which lays a line drawn from the deepest portion of the 
incisal point angle to the fulcrum. (See dotted lines Fig. 39.) The 
nearer this line in a given case approaches the perpendicular to the 
axial part of the filling the more essential is it that the point angle 
be cut in the same plane as the axial wall. Also the nearer this 
line approaches ninety degrees from the perpendicular the more es- 
sential is it that the incisal point angle be cut at forty-five degrees 
to the perpendicular of the axial wall. 

By a study of Fig. 40 it will be seen that the incisal angle of 




Fig. 40. — Drawings to illustrate the importance which should be given to the proper plac- 
ing of the incisal point angle in fillings of Class Four, plan two, with particular reference to 
the plane in which wall b — c should be cut. 

A would be effective while B would offer no resistance to exit with 
a filling pivoting at a. By materially shortening the axial walls of 
both, the point angle of B becomes effective and that of A ineffective. 

As shown in the drawings in A the dentine included in h, c, d is 
the retention produced by having dotted line a, h longer than line 
a, c. In B these lines are the same length, hence no retention. The 
filling becomes a lever to lift the gingival point angles. 

The Gingival Angles. In the study of the gingival angle reten- 
tion, we will eliminate the incisal angle and consider that it has been 
improperly laid or has been weakened and the lever force has been 
transmitted to the gingival angles. 



84 



OPERATI^TE DENTISTRY 



111 Fig. 41, a is the fulcrum and h the extreme point of the angle. 
Potted lines a-h are the radii of the circles the arcs of which the 
point angle fillings would describe in going to exit. The two 
gingival point angles should be of different depths so that they will 
describe the arcs of different circles in being drawn to exit. It is 
most convenient to make the gingivo-axio-lingual the deeper. 





Fig. 41. — A study in the proper placing and depth of the gingival angles. 




Fig. 42. — A study of the planes in which the gingival angles should be laid. 

It is also essential that the two gingival point angles be so laid 
that the circles, the arcs of which the point angle fillings describe in 
passing to exit, stand in different planes as illustrated in Fig. 42. 
Failure to observe the last two principles given removes retention 
form as regards the gingival angles. 



PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE 



85 



First Plan of Angle Restoration. (Class Four.) 

The first plan of anchorage is made by undercutting the incisal 
edge. This plan is indicated in teeth of rather thick incisal edge 
that are rather short and stocky as they have a greater bod}' of den- 
line near the angles upon which to depend. 




Fig. 43. — Cavity of Class Four, plan one, for cohesive gold. 




Fig. 44. — Class Four, plan one, cavity filled. Labial and lingual views. 
Cavity shown in Fig. 43, 

As a rule the horns of the pulp in such teeth are Avell retracted, at 
least in adult mouths, and there is less danger of pulp exposure as 
compared Avith the teeth of thin edges and angular outline. If this 
plan has been decided upon, the cavity should be cut well to the 



86 



OPERATI^^E DENTISTRY 



gingival, particularly at the gingival angles, in some cases to the ex- 
tent that the gingival wall is made convex to the incisal. 

The Gingival Point Angles should be deep and well defined at 
the expense of both gingival and axial walls. This is particularly 
true of the gi'ngivo-lingual angles, to protect against the torsion 
strain. 

To Assist the Incisal Angle. To resist the tipping strain both the 
labial and lingual walls should be slightly grooved along the axio- 
labial and axio-lingual line angles much in the same way as with 
large Class Three cavities. 

The Labial Outline should so proceed that the completed filling 
will be of about equal width for its entire length except that as it 
approaches the incisal edge it should be slightly curved to the axial. 




Fig. 45. — Shows incisal outline in Class Four, plan one, fillings with direct occlusion. 

A Rule for Labial Outlines. All cavity outlines in incisal angle 
restorations should curve to the axial as they approach the incisal 
edge. The nearer this outline approaches the central axial line of 
the tooth the greater should be the curve. AVhen the central axial 
line is reached by a cavity outline, the same should then be extended 
to involve the opposite angle. There are exceptions to the above 
rule but maximum resistance to stress is only thereby obtamed. 

The Necessity for Curving to the Axial. AVhen approaching the 
incisal edge curve to the axial that the last rods at the cavo-surface 
angle may be adequately supported. A large per cent of fillings 
where this precaution has been neglected fail, showing a primary 
fault due to the breaking away of the enamel at this point. 



PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE 87 

The Incisal Outline as it crosses the hicisal edge of thick teeth 
should have in its center a curve toward the axial caused by a slight 
groove in the center of the dentine. This groove which ends at this 
point in the cavity outline should originate at the external end of 
the incisal line angle. If there is sufficient dentine, and there gen- 
erally will be in the class of cases calling for this plan of restora- 
tion, this groove is of best service if it be a flattened groove and 
made with a small hoe or hatchet. (Fig. 45.) 

The Lingnal Outline should be the same as for large Class Three 
except in the incisal third when it should curve to the axial even 
more rapidly than the labial outline and for a longer distance, re- 
sulting in cutting aAvay more enamel from the lingual than is re- 
moved by the labial outline. This is made necessary from the fact 
that all stress is from the lingual. 

With Lower Incisors the reverse is true and it is necessary to re- 
move slightly more of the labial enamel in angle restoration, a fact 
which materially mars these teeth from an esthetic point of view. 
Fortunately we have comparatively few angles to restore on lower 
incisors, but when they are presented the fact must be borne in 
mind that they receive the major portion of stress from the inciso- 
labial direction. 

Second Plan of Angle Restoration. (Class Four.) 

The second plan of restoration is indicated in teeth that are of 
medium thickness, particularly if they are of angular build or have 
a direct contact on the incisal edge either in occlusion or articula- 
tion, and consists in the additon to plan one of what is termed the 
incisal step. The cavity proper is prepared the same as has been 
outlined in plan one up to the forming of the step. 

The Incisal Edge is cut away with a narrow-edged carborundum 
stone, the cutting being extended toward the opposite angle a dis- 
tance equal to the width of the cavity proper. The incisal outline 
should avoid both the centers of primary calcification and the point 
of coalescence, two weak places in enamel construction. The cut- 
ting should be more at the expense of the lingual side of the tooth 
by one-half to one millimeter. 

The Depth of This Step, inciso-gingivally, will depend upon the 
thickness of the cutting edge, and the probable stress it wdll receive. 
The thinner the edge and the greater the probable stress, the deep- 
er must be the step. The majority of cases will show not to exceed 
one millimeter of gold on the labial in the step portion. 

Technic of Cutting. A small round bur is then used to cut a 



88 



OPERATIVE DENTISTRY 



groove in this newly formed puipal wall, near the dento-enamel 
junction next to the lingual plate of enamel. The lingual enamel is 
then removed with a chisel thus carrying that portion of the puipal 
wall to a loAver level. This process is continued until it is at least 




Fig. 46. — Cavity of Class Four, plan two, for cohesive gold. 




Fig. 47. — Class Four, plan two, filled. Labial and lingual views. A very popular method. 
Cavity shown in Fig. 46. 

one-half millimeter to one nnllimeter loAver than the labial portion 
of the puipal Avail. This leaves the major portion of the dentine sup- 
porting the labial plate of enamel. 

The Point Angle in the Step Portion should be deepened and made 



PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE 



89 



acute largely at the expense of the pulpal wall. This will place it in 
just the right position to resist stress from the probable source and 
prevent tipping. (See Fig. 37.) 

This Second Plan is Particularly Indicated in cases of much wear 




Fig. 48. — Cavity of Class Four, plan three, for cohesive gold. 




A B 

Fig. 49. — Class Four, plan three, filled. Labial and lingual views. Cavity shown in Fig. 48. 

on the incisal, due to what is called ''end-to-end" bite. However, 
in such cases all of the exposed dentine on the incisal edge should 
be included in the step and it is not necessary to remove much of 
either of the labial or lingual plates of enamel. In such cases the 



90 OPERATIVE DENTISTRY 

step portion should be retentive throughout as it is liable to be 
worn away by subsequent wear, growing thinner from year to year, 
hence the necessity of retentive form from cavo-surface angle to the 
base line angles. 

Third Plan of Angle Restoration. (Class Four.) 

This plan is the addition to plan one of the lingual step. It is 
particularly indicated in cases of long incisors which are quite thin 
labio-lingually and subjected to a long sweep of the lower incisors 
in the movements of articulation, or what is spoken of as the ''scis- 
sors bite." 

Also Indicated in cases where the axial wall extends out to the 
enamel edge on the lingual thus removing the lingual wall. 

The Labial Outline is the same as with the first plan of restora- 
tion. The step is formed on the lingual by cutting away the enamel 
from the lingual surface of the tooth toward the central axial line 
for a distance of from one to two millimeters at the incisal edge. 

As the gingival is approached the cutting is narrowed to a point 
where the marginal ridge may be crossed at right angles to meet 
the gingival portion of the outline. This will form a Y-shaped axial 
wall of dentine facing the lingual. There should be cut a flat- 
floored groove in this dentine parallel with the remaining enamel 
wall ending in the gingivo-axio-lingual angle which should be an 
acute convenience angle. The plan gives great resistance to stress 
from lingual pressure. 

Fourth Plan of Angle Restoration. (Class Four.) 

This plan consists of resorting to all of the features of resistance 
and retention embodied in plans two and three by combining both 
the lingual and incisal steps. Each of these has been fully de- 
scribed and the method of cutting both steps to the same should not 
prove hard to accomplish. 

By this plan the maximum resistance and retention forms are se- 
cured with the minimum loss of dentine. It must be remembered 
that resistance to stress is good in proportion to the amount of se- 
curing dentine retained, hence it should be sparingly cut away. 
The removal of enamel to lay bare dentine Avherein to lay anchor- 
age is only harmful from the esthetic standpoint and is of little loss 
when taken aAvay from a surface not in view, as is the case when Ave 
cut away a portion of the lingual plate. 

Cavities in the Distal of Superior Cuspids. On account of the 
peculiar articulation of the lingual surface of superior cuspids this 



PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE 



91 



cavity has been left for separate consideration. The plan given is 
a modification of plan three, using a lingual step not unlike the oc- 
clusal step in a. class two cavity. 




Fig. 50. — Cavity of Class Four, plan four, for cohesive gold showing maximum anchorage 
vi^ith a minimum loss of dentine. The use of this plan is advised when the lingual stress is 
great. 




A B 

Fig. 51. — Class Four, plan four, filled. Labial and lingual views. Cavity shown in Fig. 50. 

Access is an easy matter as the decay is in the most prominent 
part of the distal surface and a little work with the chisel gives ac- 
cess to the cavitv. 



92 



OPERATIVE DENTISTRY 



Outline Form. In outlining the ca^'ity proper most of that which 
has been said about plan one should be followed here. 

As to the lingual outline and that of the step particular attention 
must be paid to so placing the margins as to remove them as much 
as possible from the stress of articulation. 

The Step. The lingual step is added to this cavity as it ma- 
terially assists in retention, resistance and convenience forms. 

In the laying of the walls of the step portion the particulars 
are carried out much as though the lingual surface of the cuspid 
were an occlusal surface, as next to an occlusal surface it receives 
the greatest stress in articulation. 

Axial Walls. It will be seen that this cavitv has two axial walls. 




Fig, 52. Fig. 53. 

Fig. 52. — Cavity of Class Four, modified plan three, for cohesive gold in the distal of 
the superior cuspid. This plan is sometimes used to advantage in the incisors when the 
tooth is short and stocky. In such cases the lingual step is made to include the lingual pit. 

Fig. 53. — Class Four, modified plan three, filled. Cavity shown in Fig. 52. 



The one in cavity proper is the axial, Avhile that in the step is 
termed the lingual axial wall. 

The Lingual Axial Wall shoukl be placed on a plane parallel with 
the lingual surface of the tooth. Its surrounding line angles should 
be laid just below the dento-enamel junction. 

Convenience Form in this cavity is pretty well secured by the ad- 
dition of this lingual step, as the filling is then easily built in from 
the lingual direction. Both gingival point angles in the cavity 
proper should be made convenience angles as well as the axio- 
gingivo-mesial point angle in the step portion. 



CHAPTER XVI. 

MANAGEMENT OF CAVITIES IN THE GINGIVAL THIRD, 

(CLASS FIVE.) 

Gingival Third Cavities Differ from all other cavities in the teeth 
in that they originate on perfectly smooth surfaces generally with- 
out flaw in enamel formation and without covering of any kind, or 
to state it more concisely, there seems to be no predisposing cause. 

Their Prevention is an easy matter, as the accumulation of sordes 
which is the sole exciting cause, is unprotected and of easy access to 
the brush so that patients with this class of decay are paying the 




A B 

Fig. 54. — Cavities Class Five for cohesive gold or amalgam. 

penalty for the careless neglect of the simplest forms of oral cleanli- 
ness. With these facts before us it becomes the duty of every practi- 
tioner to fully advise the patients of the neglect of their mouths in 
this particular locality, in an elfort to check farther destruction. 

The Tendency to Spread in the Enamel is a characteristic of this 
class of cavities. They usually originate near the center of the 
buccal surface near the free margin of the gum and seldom stop 
until they have extended both mesially and distally nearh^ to the 
angles. The fact that the encroachment seldom reaches the angle 
in the external enamel decay, is a point to be considered in the 

93 



94 



OPERATIVE DENTISTRY 



stud}' of extension for prevention in this class of cavities. It ap- 
pears that when the outline is carried quite to the angle that 
secondary caries rarely occurs. 

The Gingival Outline should be laid below the gum line for its 
entire length until the angles are reached when it should emerge 
from beneath the gum at a right angle to the free margin of the 
gum. 

The Occlusal or Incisal Outline should be carried to a region 
of sound enamel. Where this extension does not carry this outline 
farther than one millimeter from the free margin of the gum farth- 
er extension should be made. With teeth surrounded by a heavy 
gum, particularly if there seems to be a condition of hypertrophy 




A B 

Fig. 55. — Class Five filled. Cavities shown in Fig. 54. 

present, the occlusal outline should be laid at least two millimeters 
from the border of the gum. 

Retention Form. Retention is secured by squaring out the four 
point angles. The axial wall should generally be left as decay has 
left it in the central portion. Any subsequent cutting should be 
of such a nature as would tend to make it convex to the external, 
or so to speak, the miniature of the tooth's surface in which it is 
being cut. An effort to cut a flat axial wall mesio-distally will 
often endanger the pulp and is unnecessary as these cavities need 
no resistance form. 

In Large Buccal Decay often the gum has so grown into and 



CAVITIES IN THE GINGIVAL THIRD 95 

filled the cavity that the adjustment of the clamp and rubber dam 
is difficult or impossible. In such cases if the pulp is not involved 
much assistance is secured by packing the cavity full of gutta- 
percha base plate allowing it to crowd well down upon the gum. 
In a few days the gum will have receded or have been absorbed 
sufficiently to permit convenient access. 

If the Pulp is Involved and requires extirpation make the appli- 
cation of the devitalizing agent, covering this with amalgam which 
should fill the cavity. Care should be taken that the gingival wall 
has been planed to a solid condition. During this operation dry- 
ness may be obtained by the assistance of cotton rolls. 

"When case returns the clamp will ride on the amalgam at the 
gingival and access to the pulp may be had through the upper 
portion of the amalgam. After the pulp canals have been filled 
the dam may be removed, the remainder of the amalgam excavated 
and cavity preparations proceeded with, as well as the placing of 
an amalgam filling, under dry conditions by the use of Cotton rolls. 

If Gold is to Be Used the gold inlay is clearly indicated as pro- 
ducing the best results with the least tax upon patient and oper- 
ator. 

With Labial Cavities in the gingival third the Hatch clamp will 
expose nearly every case presented and render access not difficult 
for the introduction of a cohesive gold filling. In cases of ex- 
tensive gum recession on labial exposures the porcelain inlay is 
clearly indicated and is considered in the chapters on that subject. 



CHAPTER XVII. 

MANAGEMENT OF ABRADED SURFACES. OCCLUSAL AND 
INCISAL. (CLASS SIX.) 

Definition. Class six includes the firoiip of cavities necessary 
for the repair of injuries to the teeth through the loss of a portion 
of their articulating surfaces as the result of Avear. The condition 
is abnormal and the extent of the destruction of tooth substance 
is by no means in proportion to the amount of use to which the 
teeth have been subjected. However it will be noticed in mouths 
with teeth of short cusps, and particularly if the incisoi-s occlude 
directly upon the incisal edge, that there is an abnormal amount of 
lateral motion in the act of articulation, and in such* mouths we 
find the maximum loss of tooth substance at any given age. 

Cause Not Wholly Clear. Yet, that friction is the sole cause for 
this lesion, can not be demonstrated, as the surfaces thus affected 
do not show the exact impression of the opposing teeth, neither is 
this condition always delayed till advanced years. Cases will be 
occasionally met with in the mouths of people in middle life show- 
ing the advanced stages of this trouble. 

At the same time locations will be found on the occlusal surfaces 
of teeth Avhich at one time must have been in articulation but are 
so far lost and seemingly worn away that they could not be 
brought into occlusion. 

It Avould seem from a study of a great number of cases that 
there must l)e some causes predisposing and exciting not yet un- 
derstood. It is not impi-obable that the cause is a fault in tooth 
structure, not so much in the constituents of the tooth as in the 
lack of strength in their combination. This conclusion would seem 
plausible from the fact that teeth similarly situated and of the 
same chemical analysis are affected to a different degree by even 
slight frictioi). The bond of union does not seem to be so strong. 

The Object in Filling or in making a cavity to fill is to perma- 
nently check the loss of tooth substance by entirely covering the 
affected surface with a substance that will resist the full force of 
mastication. 

Occlusal Surfaces. In occlusal surfaces, particularly molars 
showing the first stages of general erosion, early interference is ad- 
vised. As soon as a cusp is lost it should be restored and if pos- 

96 



ABRADED SURFACES. OCCLUSAL AND IXCISAL 97 

sible built high with gold, preferably an alloy of gold, either 
platinized foil or a east inlay of gold alloy. 

This Early Restoration of cusps to their full height will tend to 
restrict the lateral motion of the mandible in mastication, which 
seems to be a factor in this dissolution. 

Cavity Preparation. These cavities should be prepared as class 
one and should be retentive throughout. 

If the Major Portion of the Occlusal Surface of a single molar is 
affected the whole occlusal surface should be lowered about one milli- 
meter and the same restoi-ed with a cast inlay, sometimes termed 
an onlay. This is advised from the fact that the occlusal side of 
the filling may better fit the surface of the occluding teeth. This 
jnay and probably Avill necessitate the devitalization of this in- 
dividual tooth when the pulp chamber should be utilized for an- 
chorage. 

If Contact Points have been reached by this cutting, a mesio-oc- 
clusio-distal cavity is imperative. 

When Wear is General opening the bite to the extent of about 
one millimeter is preferable to cutting away any more tooth sub- 
stance than is necessary for firm foundation and a correct outline. 

With Incisal Abrasion, if the wear is not excessive, the building 
on of the ''shoe," or covering the entire incisal end of the tooth 
Avith platinized gold is the best practice. The gold inlay, Avhich is 
treated in the chapters on inlays, is also of service. 

AVhen there is excessive incisal wear opening the bite to practi- 
cally normal is indicated, using gold for the posterior teeth and 
the porcelain croAvn for the anterior. 

The Entire Enamel Edge on the occlusal and incisal surfaces 
must be covered with a protecting layer of metal as with these 
teeth the bond of union seems to be very Aveak, particularly at 
the dento-enamel junction, and they will chip away if not wholly 
protected from the force of mastication. 



CHAPTER X^T:II. 
CAVITY PREPAEATION FOR GOLD IXLAYS. 

Definition. An inlay is a body placed within a previously pre- 
pared excavation. As applied to the filling of teeth it refers to the 
process whereby the filling is inserted into the cavity of a tooth in 
one piece and retained there, by the assistance of cement. 

The Materials in most common use are porcelain, pure gold, al- 
loys of gold, as well as alloys of base metals. 

The Indications for a Gold Inlay. First. In large contour 
restorations, as there is a material saving of both time and energy 
on the part of both patient and operator. Such cases, particular- 
ly with posterior teeth are frequently crowned a\ ith the shell gold 
crown with its almost universally iri-itating band, Avhen the inlay 
could be of greatei* service. 

Second. When it is difficult to maintain dry conditions for a 
long period of time about a cavity, as with large gingival cavities 
in molars and bicuspids. 

Third. When there are extensive occluding surfaces to be re- 
stored. It is much easier to cast a correct contour than to build 
up with the plugger point which is largely guesswork when the 
rubber dam is in position. 

FourtJi. When it is desired to put in a number of fillings in a« 
given short time. In such cases the operator can make the Avax 
models, and engage the help of the laboratory in completing the 
fillings while he is still busy with other fillings at the chair. 

Fiftli. When the necessary force to properly condense a cohe- 
sive gold filling is not permissible, as with loosened teeth, or in- 
valid patients. 

Gold Inlays Are Not Indicated in small cavities, or shallow cav- 
ities, unless the outline is extensive. 

The Cavity Preparation for a gold inlay does not materially dif- 
fer from that which has already been advised in the preceding 
chapters. It is possible to construct an inlay without change for 
nearly every cavity which has been correctly prepared to receive 
a cohesive gold filling. However if the order of precedure is slight- 
ly rearranged the operation is simplified. 

This Change in the Order would be to put retention form last, at- 
tending to that part of the cavity preparation after the model 
has been made and just before setting the inlay. 

98 



CAVITY PREPARATION FOR GOLD INLAYS 99 

In cases where this has not been done, or the cavity is naturally 
retentive, the retention should be temporarily covered, as will later 
be described^ while making the model. 

Change of Position of Retention Angles. It is quite ideal to cut 
just as heavy retention angles in the different classes of cavities 
for gold inlays, as for cohesive gold, only they should be laid in a 
different position and cut at the expense of the base walls rather 
than the surrounding walls, in order to give the cavity draw. 
This feature of the cavity preparation will be described as we con- 
sider the preparation of cavities by classes farther on in this 
chapter. 

The Order of Procedure for Inlays Avould then be as follows : 

1. Gain access. 

2. Outline form. 

3. Resistance form. 

4. Convenience form. 

5. Removal of remaining decay. 

6. Finishing enamel walls. 

7. Toilet of the cavity. 

8. Retention form, Avhich is given as the fourth order in other 
forms of fillings. 

Gaining Access for inlay filling is the same as that with other 
fillings as far as surgical procedure is concerned. No more tooth 
substance should be cut awa}' on this account. 

When using preliminary separation for access, there should be 
in most of Classes Two or Three cavities, more room secured, as 
this will materially assist in getting a correct wax pattern as Avell 
as aid in the process of placing the inlay. 

Resistance Form for Inlays should receive the same careful con- 
sideration as given for other fillings. AVeakened enamel walls 
should be protected not only from the subsequent force received 
in stress but from the stress of setting the inlay. Flat seats for all 
inlays are imperative. The usual steps in Classes Two and Four 
are called for as an important factor in retention to resist the tip- 
ping strain. 

Convenience Form for Inlays should not be practiced to excess. 
No convenience points are required. The major portion of con- 
venience form should be gained through separation, preferably 
slow separation. 

Removal of Remaining Decay. When it has been fully deter- 
mined that the pulp is not to be removed, some decay may be left on 
the axial wall, or in the region of the bucco -axial or the linguo- 



100 OPERATIVE DENTISTRY 

axial line angles, until the inlay has been cast and fitted. It 
should then be removed and the dentine over-lying the pulp, if 
hypersensitive to thermal changes, given a coat of cavity varnish. 
Allowing this. softened dentine to remain during the interim be- 
tween the making of the pattern and the setting of the inlay, will 
protect the pulp against irritation and save devitalization before 
setting the inlay. 

The Finishing of the Enamel Walls Avill necessarily come in at 
this point as all cutting of the external outline of the cavity must 
be completed before proceeding to make the pattern. The only 
change advisable is that the cavo-surface angle should be more ob- 
tuse, and the bevel angle should not be as deeply buried, which 
results in a thinner metal edge. 

This Avill assist in ])uniisliiiiy: tlie iiiai-izins to a closer ndaptation 
in the final finish. 

More Beveling at the Cavo-surface Angle sliould be i-esoited to 
for two reasons. Fii-st, the gold inlay should have a margin of 
rather an acute angle in order that the material may be burnished 
more closely to the margin. Second, during the process of .setting 
the inlay and burnishing the margins, the cavo-surface angle stands 
in great danger of being fractured. 

The Toilet of the Cavity for Gold Inlays. Herein lies the great- 
est weakness in inlay methods. Xo cavity margin is surgically 
clean after it has been moistened or been in contact with the inlay 
wax pattern. 

After the pattern has been formed and removed our methods 
will not permit of again planing the cavity surfaces and particu- 
larly the margins, which is the only way to render them entirely 
clean. 

Hence Ave are forced to Avash the cavity Avails just befoi-e setting 
the inlay AA'ith solvents of the substances Avhich have contaminated 
them. Without going into detail, it is advised that the cavity be 
thoroughly scrubbed Avith chloroform, then al)solute alcohol as a 
second cavity toilet, and immediately the cavity be flowed Avith the 
cement, inti'oducing the inlay under dry conditions. 

Line of Approach. In inlay Avork the cavities should be ap- 
proached from the direction in Avhich they are to receive stress 
during service. 

In AA'ithdraAving the Avax pattern and Avhen the inlay is placed, 
each should travel parallel Avith a line draAvn from the seat of the 
cavity to the source of the force of mastication. This line of ap- 
proach is good practice AAith any filling, but is more essential Avith 



CAVITY PREPARATION FOR GOLD INLAYS 



101 



the gold inlay than the cohesive gold filling, for we do not have the 
assistance of the elasticity of the dentine in retention made pos- 
sible by the use of the wedging principle in the manipulation of 
cohesive gold. 

Preparation of Cavities of Class One. 

Of the cavities of this class calling for gold inlays only the large 
occlusal surface cavities in molars are of importance. Small pit 
and fissure cavities are more quickly and easily filled by other 
methods. 

Outline Form. In laroe occlusal cavities the outline should be 




A B 

Fig. 56. — Cavities of Class One for gold inlays. Cavity side of inlays shown. 

SO carried as to avoid eminences at the crest of marginal ridge. 
AVhen this is reached on the buccal or lingual the outline should 
include the marginal ridge and at least one millimeter of the axial 
Avail be involved. All deep grooves should be included. The 
curves should be as generous as possible. 

Resistance Form. The same rules apply as to other fillings.' 
When much of the supporting dentine has been removed through 
decay or cavity preparation from either the buccal or lingual walls, 
that portion within the cavity should be covered with a thin layer 
of black wax, which prevents the wax pattern from coming in con- 



102 OPERATIVE DENTISTRY 

tact with these walls. The cast inlay will then not touch these 
walls during the process of introduction, which Avill often save a 
fracture of these walls, due to stress from within when driving the 
inlay home to 'a seat. 

The Major Portion of Retention Form comes in for considera- 
tion after the inlay has been cast and fitted and just before ce- 
menting to place. However, a flat seat and nearly parallel walls 




Fig. 57. — Class One inlay in position showing gold wire cast in the liliing. which \\.i~ 
into the wax pattern to support the long buccal arm. Cavity shown at {B) Fig. 56. 

to this seat with fairly definite angles, is necessary to guai*d against 

the tipping strain and produce proper retention form. 

Preparation of Cavities of Class Two. 

Large proximal cavities in molars and biscupids are successfully 
handled with this method of filling. 

Access. Preliminary separation is of the greatest service here 
and should be general practice as much cutting for convenience 
form is avoided, and better contact secured. 

Complete Preliminary Separation very materially facilitates the 
removal of the wax pattern as the operator does not have to be 
as careful about having his wax pattern tight against the surface 
of the adjacent tooth. In addition to the preliminary separation 
before making the pattern, it is to the advantage of the operator 



CAVITY PREPARATION FOR GOLD INLAYS 



103 



to pack the case for additional separation during the interim be- 
tween making the pattern and setting the inlay. 

Outline Form. The outline for inlay filling is much the same as 
for other methods. Care should be taken that the buccal and 
lingual walls are parallel, particularly the enamel portion of these 
walls, as the wax pattern must move directly to the occlusal sur- 
face in exit. It is equally essential in inlays that angles and sharp 
turns in outline be avoided, particularly as they will not take in 
the wax pattern and any defect in the casting exaggerates the 
nusfit. 

Resistance Form. Flat gingival and pulpal Avails are demanded 
in class two. AVeakened buccal and Ungual cusps should be re- 
nioved and replaced with the filling material. 




Fig. 58. — Cavities of Class Two for gold inlays. Cavity side of inlays shown. Black wax has 
been used in the molar to temporarily remove the retention produced by decay. 



Retention Form is best secured for vital cases by making four 
convenience angles in each case similar in size to those for co- 
hesive gold. However, these convenience angles should be laid 
down in the gingival and pulpal walls . and cut entirely at the ex- 
pense of these walls rather than at the expense of the tooth substance 
in the region of the ascending line angles. To describe the process 
more accurately take a round bur, about number one-half or num- 
ber two, sink it into the gingivo-axio-buccal and gingivo-axio-lin- 
gual point angles about the depth of the bur. To this point the 
procedure is the same as though we were going to make a con- 
venience angle for cohesive gold. Instead of sinking the bur later- 
ally into the ascending line angle and drawing it occlusally, as 



104 OPERATIVE DENTISTRY 

'with cohesive gold, we draw it toward the mesio-distal plane along 
the gingivo-axial line angle, allowing it to fade out, after going 
once or twice the width of the bur, taking the tooth substance 
from the gingival wall. Treat both lower point angles in this man- 
ner. In the step portion of the cavity follow the same procedure 
in the two point angles, cutting all tooth substances at the expense 
of the pulpal Avail. This results in giving the cavity draw to the 
occlusal and giving your inlay four lugs, which key the filling to a 
seating, particularly in the region of the gingivo-buccal and gin- 
givo-lingual point angles. It also results in placing your retention 
form high in vital cases and near the force of mastication, and in 
a part of a vital tooth which is Avell suited to stand the tipping 
strain. (Fig. 58.) 

In Non-Vital Cases tlie retention form should be phu-ed low in 
the tooth. In fact the major portion of it should be below the gin- 
gival Avail, and this is more frequently secured by the use of the 
pin inla}. AVhen the pin is not used, the pulp chamber is so shaped 
that the Avax pattern Avill shoAv a lug, Avhich can be used for the 
major portion of the retention. 

Finishing of Enamel Walls. This part of the cavity prepara- 
tion should be attended to Avith all of the care and detail that is 
required AA'hen making a cohesive gold filling. In addition there- 
to, after the planing has been done Avith a chisel, particularly 
on the buccal and lingual outline, these margins should be pol- 
ished Avith a A^ery fine grit disk. This facilitates the travel of 
the Avax on these tAvo surfaces Avhen going to exit. A chisel fin- 
ish on these surfaces results in a pattern that under the micro- 
scope shoAA's little fine projections, Avhich have gone into the rough- 
ened surface. In draAving the pattern these little projections have 
been bent and point gingivally. This results in an imperfect cast- 
ing along these surfaces and interferes Avith the fit. Whereas if 
the surfaces have been polished, a polished Avax pattern results 
and the completed inlay more nearly fits the margins. 

When the cavity on account of decay is naturally retentive or 
has undercuts these are temporarily filled and overcome by coa-- 
ering the retentive portion of the cavity Avith some substance, as 
temporary stopping or Avax of a different color than that used 
in making the pattern. 

Preparation of Cavities of Class Three. 

The gold inlay is seldom indicated, in cavities oi (.lass Three. 



CAVITY PREPARATION FOR GOLD INLAYS 



105 



An exception may be made in those Avhich are large and have 
through decay lost their entire lingual wall. 

Access. It is of a necessity from the lingual as Class Three 
cavities receive their stress from that direction. 

The Outline is the same as though a cohesive filling were to be 
made. Care should be taken that the labial level is laid on the 
same plane as the travel of the Avax pattern to exit, else this por- 
tion of the model will be distorted in removal. 

The Gin^val Wall Should Meet the axial Avail at an acute an- 





Fig. 60. — Inlay shown in Fig. 59 partly 
in place. 



Fig. 59. — Cavity of Class Three for 
gold inlaj', lingfual approach. Cavity side 
of inlay shown. 

gle and the cavity should have a line angle which might be termed 
axio-incisal. The labio-axial line angle should be slightly shorter 
than the outline of the cavity where the axial Avail meets the lin- 
gual surface. This Avill result in alloAving the pattern exit to the 
lingual. As the labial Avail, Avhich is the seat of the cavity, is frail, 
care should be taken that it is Avell supported by sound dentine, 
else the seatino: of the inlaA' Avill cause fracture of this Avail. 



Preparation of Cavities of Class Four. 

The use of the inlay should be largely restricted to non-A^tal 
cases and a pin in the pulp canal used for the major portion of 
retention. 

If the Inlay is used in Class Four plans one and three, the case 



106 



OPERATI^'E DENTISTRY 



should always be devitalized. In vital eases the inlay may be 
used to advantage in plans two and four. 

Resistance Form. In this part of cavity procedure the same 
care should be 'exercised as when using the cohesive gold filling. 




Fig. 61. — Cavity of Class Four, plan one, for gold inlay. Cavity side of inlay shown. 




Fig. 62. — Class Four, plan one. inlay in position. Cavity shown in Fig. 61. 

This is particularly true at the incisal edge, where the beveling to 
the axial should be quite generous to protect against breaking 
down of this margin due to the fact that stress comes at right 
angles to the long axis of the enamel rods. 



CAVITY PREPARATION FOR GOLD INLAYS 



107 



Retention Form. This step in cavity procedure will vary ac- 
cording to which plan of Class Four is used. In plan one, which 
as before stated should be used only in non-vital cases, a pin 
should be placed in the pulp canal and depended upon almost en- 




Fig. 63. — Cavity of Class Four, plan two, for gold inlay. Cavity side of inlay shown. Black 
wax has been used to temporarily remove undercuts caused by decay. 




Fig. 64. — Class Four, plan two, gold inlay in position. Cavity shown in Fig. 63. 



tirely for the retention. In plan two, largely used in vital cases, 
a short, 20-gauge pin of iridio-platinum or tungsten should be 
placed in the step portion of the cavity lying parallel to the long 
axis of the tooth. This small pin had best be from one to three 



108 



OPERATIVE DENTISTRY 



millimeters long, OAving to the possibilities of the case. The gin- 
gival retention may be accomplished either by using a similar pin 
to that used in the incisal, placing the hole for same in about 
the center of the gingival wall, or the plan of retention used in 
the gingival wall Class Tv\'o may be used. This consists in cut- 




Fig. 65. — Cavity of Class Four, plan three, for gold inlay. Cavity side of inlay shown. 




Fig. 66. — Class Four, plan three, inlay in position. Cavity shown in Fig. 65. 



ting the two convenience angles in the gingival wall. In plan 
three, non-vital, the pin in the root canal should be used. In plan 
four same retention used as in plan two as the case is nearly al- 
ways vital. 

The Enamel Walls should be well beveled, Avhieh will in no 



CAVITY PREPARATION FOR GOLD INLAYS 



109 



way hinder the removal of the model. IModel should make exit 
to the ineisal with a slight lingual travel. 




Fig. 67. 



Fig. 68. 



Fig. 67. — Cavity of Class Four, plan four, for gold inlay. T'lack wax has been spread on 
the labial wall before making the pattern to prevent the gold from touching this wall when 
setting the inlay for two reasons. First: It removes liabilitj' of fracture of this wall when 
setting the inlay. Second: This wax is replaced with cement and the color of the tooth is 
preserved. The wire loop secures the alinement of the two posts and facilitates handling the 
pattern. When the wire is not entirely buried, platinized gold should be used. When it is 
entirely buried tungsten may be used. 

Fig. 68. — Class Four, i)lan four, showing cavity side of pattern with pins. 




Fig. 69. — Class Four, plan four, inlay in position before removing wire loop. Cavity and 
pattern shown in Figs. 67 and 68. 

Preparation of Cavities of Class Five. 

Of this class the large buccal cavities call for gold inlays, in 
which they are the ideal filling, and should largely replace amal- 
gam so commonlj' used. 



110 



OPERATR-E DENTISTRY 



The Occlusal Wall. The axio-occlusal angle should be slightly 
obtuse, while the axio-mesial and distal angles may be nearly a 
right angle. This will permit the model to tip to the buccal in 
exit, though the gingivo-axial angle be acute. 

Preparation of Cavities of Class Six. 

The restoration of abraded surfaces Avith the gold inlay is good 
practice, inasmuch as it is possible to effectuall}' protect these 




Fig. 70. — Class Five cavity and inlay. 




Fig. 71. — Showing the necessary amount of metal for adequate protection of abraded surfaces, 

when opening the bite. 

surfaces from further destruction Avith the minimum amount of 
cutting. As is the case with the other forms of fillins: the surface 



CAVITY PREPARATION FOR GOLD INLAYS 111 

covered should be generous. If only one tooth is to be treated 
with this filling the amount of tooth substance cut away will be 
about the same as the quantity of gold in the inlay. 

However if the bite is to be raised on most or all teeth the cut- 
ting should be very slight and only enough to properly cleave 
and bevel the enamel margins. 

In vital cases either incisal, lingual or occlusal, the retention 
should be made by the introduction of short pins, iridio-platinum 
or tungsten preferred, through a matrix of pure gold, and then 
casting the contour. 

In Non-Vital Cases a single large pin should be used, or the 
model may be so made as to occupy a part of the pulp chamber 
in lieu of the pin. 



PART II 

CHAPTER XIX. 
THE MAKING AND SETTING OF A GOLD INLAY. 

In discussing the methods of making any filling, particularly 
the gold inlay, one must bear in mind that the best practice today 
may be obsolete tomorrow. In this chapter an attempt is made 
to bring out only the most popular methods at this time, as Ave 
are fully aware that new methods are continually being devised, 
which may prove of better service. In fact, since placing the first 
edition of this book on the market, there have been material 
changes in methods, which have resulted in much improvement 
in this class of fillings. However, it is a question in the minds of 
most of our prominent teachers, as to the comparative value of 
this method when considering the cohesive gold filling. If the 
excellent results obtained in the use of cohesive gold are to be 
approached in the use of the inlay, great care and pains must 
be taken with every little detail. 

The Object of the Inlay. The object of the inlay is to protect 
the cement which covers the cavity Avails and restore lost contour. 

If cement AA^ere permanent in the mouth Avhen exposed to AA'ear 
and dissolving agents, there Avould be no call for inlays, Avhich 
are really only made to protect the cement. It is therefore of the 
utmost importance that the inlay completely coA-er the cement by 
a perfect adaptation at the cavity margins and that it be so con- 
structed that it Avill maintain this close adaptation. 

In choosing the method of construction in each case the mar- 
ginal adaptation should be considered and the one selected Avhich 
promises the greatest perfection. 

History. The gold inlay is one of the oldest forms of filling. 
In fact, it is the oldest, as proved by excavations in the Orient. 
Teeth in the skulls of mummies have been found Avherein cavities 
have been croAvded full of lead, Avith the probable intent to check 
decay. Even in modern times the inlay has ahvays been prac- 
ticed more or less, and has become more popular as time goes on. 
As compared Avith the making of a cohesive gold filling, it is in- 
finitely easier, and the history of our college clinics shoAvs that 
the beginner attains a passing degree of success Avith the gold in- 

112 



MAKING AND SETTING OF A GOLD INLAY lid 

lay long before he is able to understand and successfully bring 
to bear many of the qualities of cohesive gold. 

Method Using Pattern Entirely of Wax. The cavity should be 
prepared as for any other metal filling except that the retention 
form should be omitted. In case decay has so left the cavity that 
it is naturally retentive by having excavated undercuts these should 
be filled with some substance which does not become a part of 
the pattern, and which is easily removed before setting the in- 
lay. The substances used to temporarily remove the retentive 
form, are cement, temporary stopping, modeling compound and 
wax, the preference being with the wax. 

This wax should be of a decidedly different color than that of 
which the pattern is made. (See Fig. 72.) 




Fig. 12. — Large restoration in non-vital case. Part of imr i'ui|< chamber has been filled 
with black wax to remove undercut caused by pulp removal. The weak buccal wall has been 
covered with the same material to protect it from stress from within when setting the inlay. 
It goes without saying that this wax is all removed before setting the inlay and is therefore 
replaced with the cement with which the inlay is set. 



The Filling of the Undercuts should be made to dry cavity 
Avails, and with the wax quite warm to insure its adhering, that 
it may not leave the walls to distort the pattern. The difference 
in the color of wax used will cause the detection of any particles 
which may adhere to the pattern and make their removal easy. 

By a little study and the judicious use of the above method 
much cutting for convenience form may be obviated and many 
seemingly difficult cases rendered quite simple. 

The Making of the Pattern. After the retentive form has been 
removed, the cavity should be flooded with water of ordinary 
temperature. This will render the wax within the cavity suffi- 



114 OPERATIVE DENTISTRY 



CI 



ently hard not to yield under the force necessary to introduce 
the pattern wax. It will also prevent the portions of wax from 
adhering. The wax for the pattern should then be softened, pref- 
erably in warm Avater. The wax should be sufficiently plastic to 
permit of molding Avhen manipulated in the fingers, care being 
taken that the wax is not folded upon itself as the portions will not 
adhere. Wax so folded is liable to part at the folds and come away 
from the cavity in sections. The wax should be gently shaped so 
that it can be introduced into the cavity in such manner as to come 
in contact Avith the base Avails or floor of the cavity first, then by 
slow continued pressure for about fifteen seconds made to expand 
till it entirely fills the cavity, overfloAving all margins. 

If the inlay is to replace any poi-tion of the occluding surface the 
operation should ])e done with the ru])ber dam off. The patient is 
]'e(iuested to close the teeth to full occlusion, slowly. It must be 
renieml)ei'ed that the casting Avax is only .semi-plastic aii<i moves 
very slowly, hence the best impression is obtained by moderate con- 
tinued f()]'ce, giving the sluggish Avax time to flow. Wax is really 
quite elastic ^\•hen confined and Avhen the pressure from the bite 
is removed will spring back the least bit, so that the cast inlay will 
be too high Avhen set. 

To overcome this it is good practice to have the patient again clo.se 
the teeth to occlusion Avith one layer of rubber dam ovei- the occlu- 
sal surface of the model, requesting him to maintain the ])i-e.s.sure 
for some seconds. The elasticity of the rubber dam Avill overcome 
the elasticity of the Avax. This Avill do away Avith much grinding 
after fitting the inlay to position. The pattern should then be carA'ed 
to full contour restoration and correct external surface form, and 
the Avax thoroughly burnished ai-ound the entire cavity outline. 

The carving and burnishing of the Avax is materially a.ssisted 
if the surface is Avarmed by the use of Avarm Avater. This is best 
accomplished by dipping large loosely-rolled cotton balls in Avater 
that is almost too Avarm for the lingers, carrying it to the mouth 
and foldhig about the Avax, alloAving it to remain for a few seconds. 
Upon removing the cotton the Avax Avill be found to have softened 
to a sufficient depth to be easily manipulated. In case the Avax does 
not quite reach the margin, the same should be croAvded over to 
the margins, carrying quite a body of the Avax over l)efore attempt- 
ing to burnish doAvii to the margins. If this is not done the Avax 
Avill be found to fit only at the caA'o-surface angle, leavinir a space 
just beloAv this point to Avhich the Avax is not adapted. 



MAKING AND SETTING OF A GOLD INLAY 115 

Ideal Conditions Are Obtained when the wax slightly overlaps 
the eavo-surface angle at all points in the outline, about one-tenth 
of a millimeter. 

This will give sufficient bulk for correct finishing. After the com- 
pletion of the pattern it is well to insert the tine of an explorer 
to the depth of about one or two millimeters in a convenient posi- 
tion for removal. 

The tine should be removed and the pattern chilled Avith cold 
water, the tine reinserted into the previously made hole, the pat- 
tern gently pushed to exit and then given a cold water bath. 

The Placing of the Sprue Wire. While the pattern is still carried 
on the tine of the explorer, the sprue Avire should be Avarmed and 
inserted. 

The sprue Avire should be vei-y fine, preferably copper, and in- 
troduced deep into the pattern. This use of a fine sprue Avire is of 




Fig. 73. — Some of the methods l)y which inlays may be given retentive form in large decays 

and non-vital cases. 

advantage from the fact that no considerable body of the Avax 
melts and runs back up the Avire to produce a concavity, close to 
Avhere the Avire is introduced, AA'hich happens Avhen a large sprue 
AA'ire is used. 

In selecting the position for the Avire, care should be taken that 
a location is chosen so that the contour of the surface of the pattern 
leaves the sprue Avire in all directions at an obtuse angle. A neglect 
of this point Avill occasionally result in imperfect casts near the 
sprue former. The tine of the explorer should noAv be AA'ithdraAvn 
and the resulting hole sealed by touching Avith the Avarm end of 
a small instrument. 

A good instrument for such Avork is the flattened end of a large 
canal cleaner or broach, mounted on a Avooden handle. 

Giving- the Wax Pattern Retention Form. Portions of the pat- 



116 OPERATIVE DENTISTRY 

tern should now be removed, preferably by the use of the heated 
hollow needle, in such manner as to give the cement an ample grasp 
upon the inlay, and should be equal to or more than the amount 
of retention of which the cavity in the tooth is capable. The pat- 
tern is then ready for investment. 

Method of Using Wax Pattern, Pin Attached. This method is 
of service when for any reason it is desired to have the maximum 
amount of retention. In such cases the tooth will generally be non- 
vital and a portion of the pulp cavity used for the reception of 
the pin. 

Placing the Pin. The cavity should be first freed from retentive 
form as described above, using either cement, temporary stopping, 
modeling compound, or wax, then the opening made in the root 
canal to. receive the pin Avhich is placed in position, with a light 
coat of sticky Avax on the outer end. The pin should ])e long enough 
to reach well into the body of the Avax pattern and should be iridio- 
platinum, platinized gold or tungsten. These materials will stand 
the heat of casting the inlay Avithout alloying or losing their rigidity. 

Tungsten Pins. The use of tungsten in casting gold inlays is of 
great advantage, as this material is easily cast upon Avhen the wire 
has been previously gold-plated. The wire is about six times as 
strong as iridio-platinum of the same gauge and three times as strong 
as steel. This material does not lose its temper upon being heated. 
It therefore gives us a very rigid pin in the completed work. As the 
gold will not cast to the eiiH of the pin, which has been cut off and 
is not gold-plated, it is very essential that these exposed ends be 
well buried in the wax. which can be accomplished by seeing that 
the pin does not come near the surface of the casting, or else that 
the end is bent so as to throAv the exposed surface more deeply into 
the wax pattern. With the pin in position in the cavity the wax 
for the pattern is manipulated the same as though no pin had been 
used. AVhen the pattern is withdrawn the pin sliould come away 
with the wax. In case it does not, withdraw the pin from the tooth 
and seal it into the hole it has left in the wax pattern and return 
to position to insure alignment. "Withdraw the pattern after chill- 
ing and all is ready for investment. 

Method of Using Pure Gold Matrix With Pin Soldered on, 
Casting the Contour. This method is advised as most practical in 
cavities of Class Four (first plan), when teeth ai-e non-vital, in in- 
cisal restorations vital or non-vital, in occlusal restorations, cavities 
of class six particularly in vital cases, and in lingual restorations. 



MAKING AND SETTING OF A GOLD INLAY 117 

With these lingual restorations, the amount of surface covered is 
generally quite large as compared to the thickness of the restoration 
v/hich is best termed an ' ' onlay. ' ' 

This method simplifies angle restoration in Class Four plan one 
and provides ample resistance form, without the cutting of either 
the incisal or lingual step. In such cases the alignment of the pin 
must be perfect else the inlay will not go to proper place. The 
soldering of the pin to a gold matrix gives the desired security during 
the processes of removing and investment. The cavity preparation 
is the same as for cohesive gold except the convenience angles. 
The pin is fitted to a portion of the root canal as previously given. 
A sheet of pure gold, 32 to 34 gauge is selected of sufficient size to 
more than cover the cavity by about two millimeters. This is par- 
tially burnished to the cavit}', enough to shoAV the cavity outline 
in the gold. A hole is punched in the proper position to receive the 
pin, but smaller than the pin, which should be 15 or 16 gauge. In 
case the inlay is to be used as an abutment for a bridge, the pin had 
better be as large as 14 gauge, if platinized gold is used. When 
tungsten is used, 16 gauge is amjjle. 

The operator should then place the matrix in position and crowd 
the pin through the hole to place ; then scribe the pin just external 
to the gold matrix, remove and solder as nearly in correct position 
as possible, without stopping to iiwest, using 22K solder. 

Only a very small amount of solder will be needed or should be 
used, care being taken that it is all flowed close to the pin to pre- 
vent stiffening the matrix. All should then be returned to the 
cavity and the gold reburnished to a perfect fit of the entire cavity 
outline. 

It is necessary to burnish the gold only partially into the deep 
recesses of the cavity as the pin, if of iridio-platinum or tungsten, 
will be sufficient anchorage. This can be made to equal that fre- 
quently relied on for an entire crown. This pattern must move to 
the incisal for exit and if the matrix is burnished to contact with 
the axial wall it will become fixed. The matrix should be bur- 
nished to a complete fit of the gingival wall Avhich should be flat 
and well squared into the labial and lingual angles. 

Making the Wax Contour. The matrix and attached pin are re- 
moved, and the desired contour built up by flowing the wax to 
position with a spatula, trying the whole pattern to place in the 
cavity to guide in the restoration. AYhen complete, the wax is 
chilled and removed and all is readv for investment. 



118 OPERATIVE DENTISTRY 

To Restore Occlusal and Incisal Surfaces lost from abrasion 
with inlays where the tooth is vital, nothing answers the purpose 
better than the following method. The outline of the surface to 
be covered is established. Small holes are drilled to convenient 
depths in safe locations of sufficient size to receive a 20 gauge 
iridio-platinum or tungsten pin. Three or four pins are required 
for molars and two or three for bicuspids or incisors. A pure gold 
matrix, 32 or 34 gauge, is then burnished to an approximate fit. 
The positions of the holes in the tooth Avill be outlined in the gold. 
The matrix should be pricked at these points with a sharp pointed 
instrument smaller than the pins. One pin is inserted and should 
protrude occlusally through the mati-ix for a short distance, and 
be bent at right angles. 

It is good pi-actice when using tungsten to make a loop which 
goes to the full depth of two of the holes and lies along the gold 
surface in the body of the loop, thus establishing the alignment of 
two of the pins at once. This also places the exposed end of these 
tungsten pins, to which gold will not cast, entirely away from a 
position which might result in showing: the exjiosod ends in the 
completed case. 

This pin and mati-ix are then removed and attached with solder, 
applying the solder to the occlusal side of the matrix. The matrix 
should be returned to the tooth and another pin placed and at- 
tached in the same way, repeating until all ])ins are in position, 
when the matrix should receive a final burnishing. The wax con- 
tour is then added as before described, the pattern replaced and 
articulation secured in the mouth and finally trimmed to desired 
contour. The wax should then be chilled and the entire pattern 
removed and invested. 

Method of Sweating the Contour. — Advantages. Tho advan- 
tages of this older method of making an inlay still exist where the 
inlay is to cover considerable surface and is very shallow. Such 
inlays are generally termed ''onlays." This method is advised 
from the fact that models of such nature will seldom maintain ex- 
act form during the process of removing and investment unless a 
gold matrix is used. 

If the gold matrix is used it is difficult to cast a thin layer of 
gold over the entire surface of this matrix and get good margins 
unless a large quantity of gold is melted to nu^ke the cast in which 
case the gold matrix is very liable to be entirely fused, which will 
not give the best I'esults. Speed is also a factor in this instance. 



MAKING AND SETTING OF A GOLD INLAY 119 

Many times an onlay can be flowed to the desired thickness in 
much less time than that required to invest and cast. 

Making the Matrix. This is done in the same way as though a 
greater bulk of gold Avere to be added. Such inlays must be re- 
tained by one or more pins soldered to the cavity side as pre- 
viously described. 

The matrix is burnished to perfect fit and the outline definitely 
established. The matrix should be trimmed to within about one- 
fourth millimeter of the cavity outline and reburnished and care- 
fully removed. 

The matrix is then given a coat of Avhiting on all that portion 
which is to come in contact with the tooth to prevent the solder 
from flowing on that surface. 

Sweating the Contour. The gold matrix should be then laid 
upon the soldering block and with a brush flame from the bloAV 
pipe 22K plate or 22K solder fused to the thickness desired in the 
various locations on the matrix. When a sufficient amount has 
been fused in any portion, that part of the surface should receive a 
coat of whiting. 

Gold can then be fused to still exposed surface Avithout its 
spreading to portions where it is not wanted. By this means it is 
possible to build up a given portion of the inlay, even to the add- 
ing of cusps to occlusal surfaces. 

Method of Using Sponge Gold as a Pattern. Take the sponge 
gold as bought on the market for making a cohesive gold filling 
and saturate it with any casting wax on the market. This is best 
accomplished by dipping a sufficient amount of the heated gold, 
while held in the pliers, into the molten Avax, and immediately re- 
moving to a clean surface to cool. Kemove any excess Avax. 

Making the Pattern. When this method is used any undercuts 
iu the cavity should be filled Avith cement. A portion of the satu- 
rated gold large enough to a little more than fill the cavity is 
grasped between the pliers and slightly Avarmed and carried to the 
cavity and croAvded to position and the contour determined in 
much the same Avay as amalgam is manipulated. A matrix should 
be used in class tAvo cavities, but not sufficiently high to prevent 
occluding the teeth. When the pattern has the desired contour 
form, the Avhole is removed the same as described for removing a 
pattern composed of Avax alone. 

Investing. A sprue of Avax is attached to the usual place as 
though the casting method Avere to be used. The pattern is then 



120 OPERATR-E DENTISTRY 

submerged in much the same way as a tooth is invested to have a 
backing flowed but sufficiently deep upon the wax sprue former to 
leave upon its removal a receptacle for the gold solder to be fused. 

Saturating the Model. Heat may be applied to the invested pat- 
tern as soon as the investment has set, and the wax gradually 
burned out leaving a frame^^-ork of pure gold filling the mold. 
Then scraps of 22K gold plate are placed in the hole left by the 
sprue former and all is heated to the point of fusing the 22K gold 
which will disappear through the opening and completely saturate 
the pure gold Avithin the mold. The inlay may be immediately 
chilled and finished. This method has to recommend it, speed of 
nianipulation, and is indicated in lar^-e contour restorations, where 
it is desired to use a solid inlay. 

Making the Cast. Generally considered we have three forces 
used in placing the gold in the mold ; suction, pressure, and cen- 
trifugal. Centrifugal force is the only one Avherein all atoms or 
molecules of the material are acted upon, and greater accuracy is 
obtained by this method. 

Place of Heating the Gold. The temperature of the mold at the 
time the gold strikes it, in casting, is of great importance. There- 
fore, the place where the gold is melted should not be on the body 
of the investment over the mold, for by that method we are not 
able to vary the temperature of the mold at the time of casting. 
The gold should be melted on a separate tray and the mold should 
be heated to the desired temperature independently of the material 
being cast. 

Temperature of the Mold. By a little experimenting Ave will be 
able to demonstrate that a body of molten gold contracts toward, 
first, that part which is chilled first, second toward the greatest 
body of gold; that is, Avhen the gold consists of two parts con- 
nected by a small isthmus, or in other Avords, pedunculated, there 
is a tendency for the smaller body of gold to shrink toAvard the 
larger one. The first part of the gold Avhich Ave desire to set 
through the process of chilling is that part of the inlay Avhich is 
most essential to a perfect fit. namely the margin or that AA'hich 
covers the marginal bevel and second all of the cavity Avails. 
Therefore, it is important Avhen the gold is throAvn into the mold 
that the investment Avhich forms the mold be of a temperature to 
chill the gold at first impact, bearing in mind that it should be 
Avarm enough to permit of the gold to enter the sharpest recesses. 



MAKING AND SETTING OF A GOLD INLAY 121 

When Using Pin or Pure Gold Matrix. When casting an inlay 
to a mold which contains a pin or a pure gold matrix, the tem- 
perature of the mold should be considerably higher. Particularly 
is this true when the pin is large or the amount of gold to cover 
the matrix is thin as it may be close to the margins. 

Quantity of Gold Used in the Cast. When using the suction or 
pressure machines it is quite iiecessar}^ to have a large sprue left, 
as when the amount of gold is near the size of the inlay, failure is 
liable to result owing to the philosophy of the force used in cast- 
ing. However, with the centrifugal machine, it is not absolutely 
essential that there be any considerable sprue left. Yet if we try 
to guess too closely, many failures will result from having too lit- 
tle material. Owing to the law of the shrinkage of the metal to- 
wards the larger body, the sprue which is left should never weigh 
as much as the inlay cast. A large sprue left is of advantage, as 
there is a tendency to hold the whole body of gold at a tempera- 
ture sufficient to give it time to thread its way through the sprue 
hole into the mold. It is also of advantage Avhere there is a large 
pin or matrix present, as the high temperature is maintained longer. 

The large sprue is particularly at a disadvantage when casting 
the base to pin croAvns. The low fusing pin is liable to be melted. 
There is also more danger of checking the porcelain. 

Size of the Opening. The size of the hole leading to the mold is 
of importance for a number of reasons. As a general rule the 
larger the inlaj^ and the louver temperature of both the hole and 
the material at which you cast, the larger should be the hole; it 
necessarily follows that the hole should be smaller with the reverse 
conditions. 

A small hole lengthens the time required for the stream of molten 
gold to pass to position. Hence, if the mold is cold and the mate- 
rial is not extra warm in casting a large body, the material is lia- 
ble to become chilled and the mold not entirely filled. However, 
if we are casting a small inlay, in a rather warm mold with the 
gold extra hot, the small hole is preferable as there is less liability 
of a backward shrinkage of the gold to the sprue, when cooling. 

Better results are obtained when the wax pattern is immediately 
invested, burned out and casting completed Avithout allowing the 
mold, either with the pattern in position or burned out, to lay over 
night. If it must lay over night, it is best to burn out the wax and 
thoroughly heat the mold, as less change takes place thereafter in 
the investment. In this connection vour attention is called to the 



122 OPERATIVE DENTISTRY 

findings of Prothero in the expansion and contraction of plaster 
paris in the various periods following its mixture with water. 

Finishing- the Inlay. AVith any of the processes of making an 
inlay there are liable to be some imperfections which Avill be seen 
upon removing from the investment. If these are on the cavity 
side of the inlay and are of any considerable size it will probably 
be necessary to make a new pattei-n. If they are only slight and 
are in the form of little pedunculated masses they can generally be 
removed without injury to the filling. If the contour shows that 
the mold did not entirely fill the necessary amount to complete 
contour, and the margin is not involved it uiay be sweat on using 
a gold of lower fusing point than that of the inlay. Another 
method is to make a gold amalgam and ])uild to the desired eon- 
tour. Then the inlay should be subjected to lieat gi-adually raised 
to nearly red heat when the mercui-y will be volatilized leaving the 
pure gold fused to the position desired. This gold amalgam is 
made by adding mercury to cohesive gold foil, pellets or fiber 
which have been annealed, mixing thoroughly in the palm of the 
hand and applying immediately to place. AH exposed surfaces of 
gold inlays should receive a hio:h polish before setting, omitting 
a line about one-fourth of a millimeter next to the entire margin. 

Setting the Inlay. The inlay should be Avashed with water and 
dried; then dipped in chloroform to remove any oil that may have 
adhered from the hands. The cavity should he freed from all for- 
eign substance, given complete retentive form, bathed with chloro- 
form and alcohol in the order named and the surface of the cavity 
entirely covered with cement. 

The inlay is given a coat of cement on its cavity side from the 
same mix and gently but firmly moved to position using hand pres- 
sure assisted by light blows from the mallet. The inlay should be 
subjected to pressui-e directed toward the seat of the cavity for 
some minutes Avhich Avill in a measure ovei-come the tendency to- 
ward displacement caused by the expansion of the cement. An in- 
lay may be finished at its margins within thirt\' minutes from set- 
ting, but it is better if this step is attended to at a subsequent 
time. 



CHAPTER XX. 

MANIPULATION OF COHESIVE GOLD IN THE JMAKING OF 

A FILLING. 

Physical Properties. The pliysieal properties most desired in a 
filling are found in cohesive gold to a greater degree than in any 
other filling material, which places it at the head of the list as a 
means of restoring lost contour and preventing recurrence of de- 
cay. It is not affected by the fluids of the mouth; it may be verj^ 
perfectly adapted to the walls of the cavity ; the shrinkage and ex- 
pansion range in varying temperature is very slight ; the cavity 
can be filled iunnediately upon freshly cut surfaces before they 
have been contaminated, an advantage over the fused inlay; and 
Avhen sufficiently condensed it possesses a greater specific gravity, 
hence density, than a fused inlay of pure gold. Hammered gold 
Avill flow under sufficient stress and always in proportion to the 
load, when it ceases to flow, unless the load is increased — a 
marked distinction between it and amalgam. This quality of gold 
makes it possi])le to build a filling which Avill at once sustain the 
force of mastication provided it has received sufficient aggregate 
w^eight during the process of introduction. This physical prop- 
erty of gold is also of service in that it does not farther compress 
Avhen firmly Avedged between the Avails of living dentine Avhich are 
elastic and retain a certain amount of residual elasticity Avhich 
permanently grasps the unyielding gold. The expansion and con- 
traction of gold under the A^arying oral temperatures is fully com- 
pensated for by this residual elasticity of the dentine so that the 
closely adapted cohesive gold filling is at all times in perfect 
adaptation. 

The Objectionable Qualities of Gold. Gold is a good conductor 
of thermal changes, hence endangers the health of vital pulps. The 
color is an objection in anterior positions, and the process of build- 
ing a filling is comparatively sIoav and taxing on patient and 
operator. 

Welding of Gold. Gold Avelds cold A\'hen properly prepared, is 
absolutely pure, and the contacting surfaces are clean. Any alloy 
in its substance (excepting platinum) or foreign substance upon 
its surface totally destroys this quality, until such substances 
are removed, Avhen the property of Avelding cold again returns. 

123 



124 0PERATI^^: dentistry 

If tlie Surface of Foil Becomes contaminated with a non-evapor- 
able substance the injury is permanent. 

To Protect tlie Surface of Gold. Place in the drawer where the 
gold is kept a small pledget of cotton or spunk saturated with am- 
monia. 

Ammonium salts will form on the surface of the gold, Avhich are 
easily volatilized by heat, leaving the gold clean. Before anneal- 
ing such gold will be found thoroughly non-cohesive. This meth- 
od of treating the gold to the fumes of ammonia Avill obviate the 
necessity of keeping more than one kind of gold on hand, as all 
will be non-cohesive till annealed and can be used in either form. 

Annealing Gold is for the sole purpose of cleaning the surface 
of the gold by volatilizing any film that may have collected. 

The Degree of Heat is about 1100°F., or just below red heat. 

In the daylight this color is not apparent, but on a dark day 
the dull red color should show. The gold is not materially injured 
if carried to the full red of 1200 or 1300 degrees, but in no case 
should the melting point be reached, as it destroys the possibility 
of adaptation to the Avails of the cavity, or the surface of the gold 
already in place. 

Methods of Annealing. The electric annealer is by far the most 
satisfactory means, as it is possible to always obtain the same de- 
gree of heat for a continued period. 

Tlie Next Best Means is to place the gold on a tray above a flame, 
thus separating the flame from the gold, preventing contamination 
of the gold with carbon, and various gases which are frequently met 
with in combustion. 

Gold Should Not Be Annealed hy Passing It Througli flic Open 
Flame of either gas or alcohol, holding the gold either on a plug- 
ger point or the foil carriers. This is quite a common practice, 
which should be discontinued. In the first place, heating the gold 
with the open flame frequently contaminates its surface, to the 
injury of its welding properties. 

Also that portion of the gold next to the carrier is not sufficient- 
ly heated and remains non-cohesive, a fact which is shown by the 
subsequent pitting of the surface of the filling during service by 
the flecking off of these non-cohesive particles. 

Specific Gravity. The specific gravity of the cast gold inlay is 
about 19, varying the fraction of a point. 

It is possible to condense a cohesive gold filling when confined 
between the walls of elastic dentine so as to obtain a slightly 
greater specific gravity than the cast inlay. However, this desrree 



COHESIVE GOLD IN THE MAKING OF A FILLING 125 

of solidity is not possible of attainment unless the gold is con- 
fined and the wedging principle is taken advantage of. 

Cohesion of Gold. The surfaces of pure gold when absolutely 
clean readily cohere. This cohesion is brought about by the fric- 
tion of the surfaces of the gold when in absolute adaptation. The 
degree of cohesion is in proportion to the friction. The friction 
is in proportion to the load, the extent of the surfaces in opposi- 
tion and the speed of the travel of the surfaces one upon the other. 
Hence, the greater the load, the smaller the surface, and the more 
rapid the movement of one surface upon the other the greater 
the cohesion. Polished surfaces of gold must be brought into co- 
adaptation in order to get cohesion. The smaller the surfaces and 
the thinner the sheets, the less load and speed will be required. 

The Serrated Plugger Points are used in condensing cohesive 
gold for the following reasons : That these polished surfaces may 
be kept small and uniform; that great pressure (load) may be eas- 
ily exerted on the polished planes previously left in the surface 
of the gold by the wedge-shaped serrations. The mallet is applied 
to give the additional factor in friction (speed) as the fresh gold 
is moved over these small polished surfaces. The above conditions 
are obtained with the least exertion on the part of the operator 
and annoyance to the patient by the serrated plugger point, which 
is made of a collection of pyramids which act as so many wedges 
and exert great lateral force (load) upon the polished sides of 
their previous impression. That gold coheres to polished surfaces 
can be easily demonstrated by taking any cohesive gold filling 
and burnishing its surface to a glossy finish. Pellets of gold from 
the annealer will readily cohere and the filling may be continued 
to full contour by applying a steel burnisher Avith heavy pressure 
drawn over the surface of the fresh gold. This process proves that 
burnished gold coheres, but it is sIoav and laborious and objection- 
able to the patient, hence the serrated plugger point which ac- 
complishes the same result, the friction of polished surfaces of 
gold under pressure, causing their welding. 

Bridging is the term applied to that faulty manipulation which 
results in air spaces within the body of the filling, caused by the 
gold failing to reach the bottom of the indentations of the serrated 
plugger point. 

The Cause may be insufficient pressure being given the plugger 
point, the gold thereby stopping short of the bottom of the serra- 
tions, or it may be caused by too much light malleting, going over 
the gold surface repeatedly thereby bending down the crests of 



126 OPERATIVE DENTISTRY 

the pyramids thus choking them to the entrance of the gold. 
Again, it may be caused by changing to a plugger with a less num- 
ber of serrations to the millimeter, or one wherein the serrations 
are not as deeply cut, resulting in a collection of pyramids that do 
not reach the bottom of the indentations made by the previous 
plugger. 

Plugger Points Should Have the Same Sized Serrations. Each 
operator should have a set of gokl plugger points same denomina- 
tion as to the cuttings on the Avorking point to use in the same fill- 
ing. When forced to change to one of different sized serrations the 
surface of the filling should l)e gone entirely over with the new plug- 
ger to be used, before adding additional gold. This will create a new 
set of facets to accoimnodate the gold added with the new instru- 
ment. (See Figs. 176A and 17GB.) 

A little care in this resy)ect will greatly increase the specific grav- 
ity of the cohesive gold filling. 

Rotating the Plugger in the Fingers Should Be Avoided. The ser- 
rations are cut on the scjuare and unless the point is rotated one- 
fourth of a circle each time the pyramids will I'ide the crests of the 
indentations, whereas if the shaft is held in one position as described, 
the leverage produced by the plane on the surface of the plugger 
point coming in contact with the plane on the surface of the tilling. 
will twist the plugger point to position Avith each blow of the mallet. 
All this will prove plain to the vision if the field of operation is 
viewed under a high power lens while ojierating with a serrated 
plugger on the surface of gold in a technic block. 

The Size of the Plugger Point. This depends entirely upon the 
force with which it can l)c used. It would seem from all the facts 
at hand that a point with the surface of one square millimeter should 
be regarded as the maximum. The force required to proj^erly con- 
dense gold Avith a ])oint of greater surface, is either not permissible 
in many cases or often not possible Avith the operator. A point of 
one square millimeter should receive a load of 15 pounds pi-essure at 
each contacting of the point. 

At the same time points of much less than one-half millimeter 
Avill chop the sui'face by disturbing the gold close to the point Avith 
each impact; hence aa'c are limited to a narrow range as to sizp i^f 
points. 

Preparation of the Foil. The gold foil may be used fn.m the 
book as it comes from the dealer, and shaped as desired by the oper- 
ator, or it may be purchased as cylinders, squares, ropes and various 
other forms. 



COHESIVE GOLD IX THE MAKING OF A FILLING 127 

The shaping should be done without bringing the gold in direct 
contact Avith the fingers,, and all manipulation and cutting should be 
done previous to annealing. 

The Application of the Foil. In whichever form the foil has been 
shaped, it should be so placed upon the surface of condensed gold 
that the leaves laj' flat. If the pellets are placed so that the leaves 
of gold are crumpled in packing to place the specific gravity will 
not be as great in the finished filling. Neither will the cohesion be 
as perfect. 

Sheet gold has left in it a certain amount of spring even after an- 
nealing that has to be overcome if folded. The less handling of the 
sheets in folds when packing the better the result. The gold should 
be grasped by the carriers with as small a bite as possible to prevent 
precondensation and carried to the position desired and condensed, 
with no attempt to shift its position ])y pushing or poking it around 
over the surface. 

If the pellet is placed near a wall, it should be placed so that it 
lies fully against that wall that it may be crowded for room when 
condensed. Short of this will hinder the wedging principle in pack- 
ing. If the new pellet is to come out to contour it should reach 
slightly beyond contour and be l)urnished back to contour with a 
flat-faced steel l)urnisher. 

The Forces Used in Condensing Cohesive Gold. Theie are two 
principal forces used in condensinu' cohesive gold, hand pressure and 
blows from the mallet. These may ])e either alone or one following 
the other or in combination ; the last named is the most popular, the 
least taxing on patient and operator and produces as great specific 
gravity in less time. However, the best results are obtained by us- 
ing each method at given times in the process of building most fillings. 

To Illustrate. Hand pi'essure alone should be used in the filling 
of convenience angles. Also Avhen on account of position the force 
must be applied at nearly a right angle to the wall against which 
the gold is being condensed, as in starting a filling and when cover- 
ing the seat of the cavity with the first one-half millimeter of gold. 

AVith the plugger point pointing directly at a dentinal wall, with 
a thin layer of gold between, the elasticity of the dentine causes the 
gold to rebound when struck a blow with the mallet. In such posi- 
tions the closest adaptation is secured by hand pressure alone which 
should be applied with a rocking motion secured by swaying the 
outer end of the plugger from side to side for a distance of, say one 
inch, at each change of position. 

Hand Pressure Alone is also of most service Avhen packing gold 



128 OPERATI\'E DENTISTRY 

against thin walls. Again in cases where the condensing force should 
be applied at an angle to the long axis of the shaft of the plugger 
point as sometimes met with in distal cavities in posterior teeth with 
a distal inclination. Hand pressure alone is required when it be- 
comes necessary to use force at an angle which would tend to unseat 
the filling. 

A filling should never receive a blow through the plugging instru- 
ment when that instrument does not point quite directly toward 
one of the inner walls of the cavity, preferably the seat. 

Mallet Force Alone is of service in adding the last portions of 
gold to an occlusal surface when adding thin layers of gold at each 
time, resulting in a very hard surface. 

A Good Rule is to increase the hand pressure (load) both in fre- 
quency and weight as you increase the thickness of the -pellets ap- 
plied, and as the angle at which the f?old is driven to a dentinal wall 
approaches a right angle. 

The Different Plans of Mallet Force. 

Hand Mallet. By far the best mallet force is the liand mallet 
driven by an experienced assistant. By this method the operator is 
able to vary the amount of hand pressure (load) and its relation to 
'the mallet force (velocity) at will all through the filling, as well as 
at different points in the condensing of a single pellet of gold, a point 
of no small consequence. 

The Automatic Mallet. It has l)een attempted to imitate this 
combination method in the automatic plugger, and is today the best 
substitute for the hand pressure and assistant mallet method, but 
it must be regarded as a substitute only and supplies a need in the 
absence of better facilities. 

Power Mallet. Power mallets either electric or meclianically 
driven by the engine are of service in that part of each filling where 
mallet force alone is indicated as previously described. But this 
is such a small proportion of each filling that most operators do not 
care to bother with them and few have them at hand. 



CHAPTER XXI. 

MANIPULATION OF COHESIVE GOLD IN THE MAKING OF 
FILLINGS BY CLASSES. 

Class One. Pit and Fissure. 

This class of cavities is the easiest of all in that they are sur- 
rounded by solid walls of dentine with generally only one wall miss- 
ing, which is the means of access to the cavity. 

Starting the Filling. In the case of a small pit cavity it is gen- 
erally well to start with a piece of gold that is sufficiently large to 
more than cover the internal wall and condense the greater portion 
with a rather large plugger point using hand pressure alone on this 
piece. With occlusal cavities the inner wall is the pulpal wall. 
When the cavity is in an axial surface it is the axial wall. 

A second pellet of gold may be added and- condensed in the same 
way. The mallet force should now be used on a smaller plugger 
point going entirely around the cavity close to the walls holding the 
shaft of the plugger at an angle of about 12 degrees centigrade to 
the wall against which the condensing is being done. 

In Occlusal Cavities the condensing should be in the central por- 
tion first; then next to the distal wall; then along the buccal and 
lingual Avails and lastly the mesial wall. This plan of procedure 
pertains to each separate layer of gold as it is applied when treat- 
ing simple occlusal pits. 

In Buccal Cavities the order of stepping is: first, center; second, 
gingival ; third, distal ; fourth, mesial ; fifth, occlusal. 

When the Cavity Has a Long Irregular Outline caused by the 
following out of one or more rather long fissures the plan is the same, 
except that the most distant arm of the cavity is filled first, allow- 
ing the gold to gradually build toward the operator's viewpoint, 
covering the base wall, portion by portion, with the plugger point 
alwaj's at the given angle to this base wall, which permits of the 
use of mallet force after the first pieces of gold have been securely 
anchored along the disto-pulpal line angle. 

Class Two. Proximal Cavities in Bicuspids and Molars. 

Beginning the Filling. There are three distinct methods of start- 
ing a filling of cohesive gold in this class of cavities. It is well if 
both gingival point angles are sharpened to a convenience angle. It 

129 



130 



OPERATIVE DENTISTRY 



will not suffice to have these made into the form of a round hole or 
slot, but they should be shaped up to the distinct Avedge shape. This 
shape will cause the condensed gold to crowd the elastic dentine on 
all sides as it i« driven to place and insure the stability of the first 
piece of gold. If this small convenience angle is not sharp «t its 
deepest point, but has a flat wall or seat, the mallet force is pre- 
cluded as that flat wall will not permit its use, the elasticity of which 
will cause the gold to rebound when struck a blow, whereas when 
this point is sharp and the approaching sides leave a wedge-shaped 
opening the gold is firmly grasped when driven to position. Atten- 
tion to this small detail will make easy starting of such fillings. 
As to the Three Plans of Starting Class Two. — The First Plan, 




Fig. 74. — Starting cohesive gold, first plan. 



and probably the most popular, is to fill one convonieiice angle, the 
one the farthest from the view]Mnnt of the operator, and while sup- 
porting this in position with a suitable instrument l)uil(l alonir the 
gingivo-axial line angle to the other point angle. 

A Second Plan is to fill each point angle separately and join the 
two with a third piece of gold laid along the gingivo-axial line aniile. 

A Third Plan is to start with a quantity of gold sufiicient to fill 
both point angles and cover the connecting line angle as well as a 
considerable portion of the gingival wall next to the axial. This last 
plan is one used by some experienced operators and is well to be at- 
tempted when working for speed. The beginner will do well with 
the first plan. 

The Order of Stepping the Plugger in Class Two. AViih each 



COHESIVE GOLD IX THE MAKING OF FILLINGS BY CLASSES 



131 



pellet of gold added, the wedging principle is made most effective 
by the following order of stepping: Center of filling first; contour 
second; ascending line angles third; surrounding walls fourth and 
against ascending cavo-surface angles fifth, keeping the long axis 
of the plugger shaft at about a twelve degree centrigrade angle to 
the axial, buccal and lingual walls. 

When the Gold Extends Beyond Contour it should l^e burnished 
back to correct position and the plugger again stepped along the 
contour, holding the plugger close to a line of the long axis of the 
tooth, instead of striking the gold at nearly a right angle to this line, 
a practice so common with operators, and one that has a tendency to 
unseat the filling and separate the laj^ers of the filling already con- 
densed. 

The Progress of the Filling should ])e kept on a plane parallel 




Fig. 75. — Starting cohesive gold, second plan. 

to the plane of the gingival wall and kept in this plane to near the 
completion of the filling, having a strict care as to complete contour 
in the proximal, as the filling advances. 

Covering the Pulpal Wall. There are two plans of covering the 
step portion in Class Two. Tlie Fwst Plan. The first and most 
common is to build the cavity portion to a level of the pulpal wall 
and gradually cover the pulpal wall by allowing each pellet of gold 
to extend a little farther than the previous one out over the pulpal 
wall till the pulpal point angles have been reached. 

Tlie Second Plan is to start an independent body of gold in the 
pulpal point angles, in one of the three ways outlined in starting the 
cavity portion on the gingival wall and finally uniting the two por- 
tions of the filling. Whichever plan is used nothing should be done 



132 



OPERATIVE DENTISTRY 



in the wa}^ of covering the pulpal wall till the gold in the cavity por- 
tion has reached a level with the axio-pulpal line angle. 

The Contact Point. The building of contact point should receive 
special attention when the proper height of the filling has been 
reached. The gold should be thoroughly condensed against the prox- 
imating tooth much in the same manner as it is wedged against the 
walls, and should receive extra mallet ing to insure extreme hard- 
ness. 

Position of Contact Point. When the proximating tooth is in- 
tact, the contact point should be in about the same position as it 
was previous to decay, and should be a contacting point and not sur- 
face or a line of contact. This should round away from this point 




Fig. 76. — Starting cohesive gold, third plan. 

ill much the same manner as do the surfaces of two marbles when 
touching, and has come to be spoken of as the ''marble contact.'' 
(See Fig. 26.) 

Moving Contact Point Flush to Occlusal. The contact point 
should be moved occlusally when both promixating surfaces are to 
be restored, one a mesial and the other a distal filling in the teeth 
making up the proximal space being considered, and when there has 
been considerable occlusal wear. This will result in a contact point 
from which the surfaces round away in all directions except toward 
the occlusal surface and is known as the ''half marble contact'' ad- 
vised for the above condition only. In this connection attention is 
called to the immunity to decay of proximating surfaces where the 
''half marble contact" has been produced by occlusal wear. Many 
instances are seen where caries ah'cady started in such spaces have 



COHESIVE GOLD IN THE MAKING OF FILLINGS BY CLASSES 133 

ceased to progress because of the cleanliness- of such surfaces, due 
to the lack of the egress of food substances. 

The Last Portions of Gold. After leaving contact point the last 
portions of gold are added to restore normal contour or as near that 
condition as occlusion and articulation will permit giving special 
care to complete covering of the cavo-surface angle at all points. 

Filling Class Two With Matrix in Position. This may be done, 
and is advised by some operators, Avho advance the theoiy of addi- 
tional condensation due to the presence of the substitute for the 
missing wall. 

When the matrix is used it should not be adjusted till the gin- 
gival cavo-surface angle is covered. It should be thoroughly wedged 




Fig. n. — Ikn-nishii'.g Ijack excess gold foil in covering the gingival margin. 

at the gingival. The matrix should be removed just before the gold 
has been built to the height of contact point. 

The Use of the Separator in Class Two. In cases ^rhere prelim- 
inary separation has not been made, a mechanical separation should 
be adjusted and tightened at short intervals to the full extent of 
safety. This will permit of better and more thorough finishing of 
contact point as the slight space resulting will be taken up, upon 
the removal of the separator. 

Class Three. Proximal in the Six Anterior Not Involving the Angle. 

Starting the Gold, in cavities class three, is the same in large or 
small cavities. The gold is first condensed into the wedge-shaped 
convenience angle farthest from the viewpoint of the operator which 
is the gingivo-axio-lingual angle. The gold is kept in this triangular 



134 



OPERATIVE DENTISTRY 



form by covering equally rapidly the three walls forming the angle ; 
the gingival, axial and lingual walls, keeping the shaft of the plug- 
ger pointing all the time at the point angle primarily covered. 
"When the gold has been built out along the gingivo-lingual line 




Fig. 



-Covering the gingivo-lingual angle with cohesive gold. 



angle to the cavo-surface angle great care must be taken at this stage 
of the filling that the linguo-gingival angle is covered and the gold 
built to full contour, as this is the only time it can be correctly done 
with the force directed in the right direction. As the jjold 



COHESIVE GOLD IN THE MAKING OF FILLINGS BY CLASSES 135 

the height of the gingivo-axio-labial angle this shdulcl be thoroughly 
filled and the filling continued, maintaining the same level of the 
gold, restoring full contour past contact point which should be well 
condensed and burnished. 

Filling Incisal Angle. Shortly after passing contact point the 
gold should be advanced along the axio-lingual angle to the incisal 
angle which should then be filled using hand pressure alone as the 
direction of the force will not permit of the use of the mallet. The 
filling should then be completed with the plugger point still directed 
toAvard the angle where gold was first condensed, the last portions 
of gold being added to the labial portion of the filling at the incisal 
extremity. 

With Lingual Approach in Class Thi-ee the Avhole plan is re- 
versed. The gold is first built into the gingivo-axio-labial angle. 
The plugger point is maintained in a position pointing at this angle 
as the filling progresses, till the last additions of gold are to the 
lingual surface at the incisal extremity, all the while the operator is 
working to the image reflected in the mouth mirror. 

The Lingual Approach Is Advised in cases where ani])le prelim- 
inary separation is secured or when the lingual wall is wanting and 
the axial wall meets the lingual cavo-surface angle. That said about 
the use of the mechanical mallet in Class Two applies to Class 
Three with equal force. 

Class Four. Proximal Cavities in Incisors and Cuspids Involving 

the Angle. 

The removal of the incisal angle permits of the plugger point be- 
ing used in an ideal angle to the walls and allows the force being 
applied more nearly from the direction that the subsequent force of 
service is received. 

Starting the Filling. These fillings are started as has just been 
described with Class Three ; however, the gingival wall should be 
most rapidly covered and the plan of building similar to that de- 
scribed for Class Two, keeping the surface of the gold parallel to 
the plane of the gingival wall, restoring lost contour as the filling 
advances, and maintaining the plugger point at about 12 degrees 
centigrade to the surrounding walls. 

The Final Portions of Gold should l^e condensed on the extreme 
incisal angle with the shaft of the plugger point still maintained at 
an angle of 12 degrees to the plane of the axial wall. 

The Layers of Gold in Class Four should i-eceive some attention 
and what is said in this connection is true of all contour restora- 



136 OPERATI\TE DENTISTRY 

tions subject to great stress. Not a little trouble has been experi- 
enced in the breaking of such fillings through given lines of fracture. 
These should be noticed and the layers of gold leaf so placed as 
to cross these lines. The tensile strength of the sheets of gold is 
greater than the usual cohesion obtained giving a filling more strength 
across the laminations than parallel Avith them. 

Class Five Cavities in the Gingival Third. 

Class Five cavities in the gingival third need no special mention 
as they are built under the rules already outlined in Class One. 

The gold is usually started in the disto-axio-gingival angle and 
carried along the gingivo-axial line angle to the other gingival point 
angle. The gingival wall will ])e the first wall to be completely cov- 
ered. The mallet force should not be directed at a right angle until 
that wall has been covered with a considerable layer of ^old. 

Class Six. Abraded Surfaces. 

These cavities are built the same as large flat cavities in the same 
surface, the principles of which have been given. 



CHAPTER XXII. 
FINISHING GOLD FILLINGS. 

Secondary Consideration. When a gold filling has been built to 
its full size, the entire surface should be gone over with a plugger 
point of moderate size. The point should be stepped so as to cover 
every accessible part of the filling. 

A light mallet with a hard surface should be used. A two ounce 
steel-faced mallet is preferred. 

Burnishing. All accessible parts of the surface should then be 
thoroughly burnished with a steel burnisher. The egg-shaped bur- 
nisher is of most universal use as it will reach most positions. 

If the filling is a proximal filling of Classes Two, Three or Four, 
a thin steel hand matrix should be forced between the filling and the 
proximating tooth to burnish the contact point and to better con- 
dense and harden the filling at this place. This is done by swinging 
the handle back and forth describing the part of a circle, till there 
is more or less freedom of movement of the burnisher. 

Following This Secondary Condensation the process of smoothing 
the surface with abrasives begins. The first efforts should be to find 
cavity outline, second, to correct contour in localities where an ex- 
cess has been built and third, to polish the contact point. 

This is best accomplished by the use of small carborundum stones 
on occlusal surfaces, disks on buccal, lingual and labial contours, 
and narrow coarse strips in the proximal, gingivally from contact 
point assisted by the use of file cut burnishers. 

Attention should first be given to all parts of the filling except 
contact point Avhich, in all proximal fillings should be the last place 
to receive finish. 

The Use of the Saw in the proximal space in the finishing of the 
filling cannot be too strongly condemned. In the first place no cut- 
ting instrument, or coarse abradent, as strips or disks, should be 
made to pass contact point except where there has been ample pre- 
liminary separation and the return of the teeth to position is relied 
upon to close the resultant space. Again there is no excuse for build- 
ing an excess of contour sufficient to engage the bite of a saw blade. 

The Excess at the Gingival should be slight, and it, with the ex- 
cess fullness in the embrasures, should be filed away with the files, 
or whittled off with the burnishing knife, the edge of which should be 
keen. The files should be carried through the embrasures as far to- 

137 



138 OPERATIVE DENTISTRY 

ward the center of the filling as possible and drawn directly outward 
and over the edge of the filling out to the external enamel surface. 

The Finishing Knife should be engaged into the substance of the 
gold and 'drawn 'from the gum and at the same time outward, tak- 
ing off only a small portion of gold at each cut. 

Coarse Abrasives, as carborundum stones and coai-se disks and 
strips, should be abandoned as soon as a near approach to the cavo- 
surface angle is reached,, and the files, plug-finishing burs, and knife 
edged instruments resorted to. to bring into view the exact cavity 
outline, after which the finer strips and disks should l)e employed to 
bring gold and tooth substance to an exact level at the cavo-surface 
angle for the entire cavity outline. 

Finishing Strips in the Proximal. To reduce the rpiantity of gold 
from contact point to the gingival, a coarse finishing strip sufficient- 
ly narrow to reach from the gingival outline to near the contact 
point only, is of advantage. This sti-ip is inti'oduced ])y sharpening 
one end and passing through the embrasure below contact point and 
then drawn back and forth till the desired surface is secured. 

Fine narrow linen strips ai'C then used in the same Avay to give 
a final finish to this place of difficult access. 

When the Entire Cavity Outline Has Been Exposed and the sur- 
face otherwise made ready for the final finish the separator should 
be tightened another degree, when it will be found that a broad fine 
linen strip will easily pass contact point. This should ])e given three 
or four sweeps with this Inroad strip not too tightly drawn, when 
the contact point should be considered finished. 

The separator should be gradually loosened and removed, the ru))- 
ber dam removed and the filling tested for occlusion and articula- 
tion and properly shaped. The filling should then receive a thorough 
finish, with wood points, leather wheels and tooth cleaning brushes, 
carrying first pumice, then whiting, till the surface of the filling is 
as smooth as the external enamel sui'face. 



CHAPTER XXIII. 

MANIPULATION OF AMALGAM IN THE MAKING OF A 

FILLING. 

Definition. Amalgam is a composition of mercury Avith one or 
more other metals. It is most commonly combined with two or more 
other metals which have been previously alloyed and finely divided 
either as shavings or filings to facilitate union Avith the mercury. 

History. Amalgam for the fillinu- of teeth Avas. introduced into 
Fi'ance alKjut the year 182G by M. Teveau, Avho called it ''sih^er 
paste." This Avas composed of silver and mercury alone, and must 
have given very unsatisfactory results as compared Avith those se- 
cured in the use of our modern alloys. 

Reception. The use of amalgam A\as given a most unwelcome 
reception ])y the i)rofession at large, Avhile the converts of the ''ncAv 
process" were e(iually emphatic in their praise of t"he new filling 
Avhich ''would certainly cheapen dentistry, and harm the profession." 
But time has proved amalgam to l)e a ])lessing to the poorer classes 
in that it brings dentistry Avithin the reach of all purses and has 
thereby proA'cd of advantage to the dental ])rofession by broadening 
its field of usefulness. 

While amalgam has many faults and should generally be avoided 
Avhen finance Avill permit, the fact still remains that more teeth haA^c 
been saved through its use than Avith any other filling material. 

However the percentage of salvage is greater Avith gold, Avhich 
forces amalgam to second place. 

The Properties of Amalgam Avhich render it of value as a filling 
material are: First, its plasticity eliminating access form in caAdty 
preparation, making possible the building up of lost contours in inac- 
cessible places in the mouth, AA^here couA-enience and access forms are 
hard to secure, sufficient for the manipulation of gold either co- 
hesive or as an inlay ; second, its property of being but slightly af- 
fected by the oral fluids, and the fact that it is fairly stable as to 
bulk and shape : and last, but not least in the minds of many pa- 
tients, we are sorry to say, is its cheapness, as most dentists see fit 
to build fillings of amalgam for a much smaller fee than gold. 

The Objections to Amalgam are : Its tendency to discolor both 
as to its exposed surface and the teeth Avith AA^iich it has been filled 
due to slight leakage Avith old fillings; its comparatively large ex- 
pansion and contraction range ; its continued floAv under load ; its 

139 



140 OPERATIVE DENTISTRY 

poor edge strength; its spheroiding during setting, when not prop- 
erly mixed from a perfect alloy. It is also liable to injury between 
the time of introduction and complete setting through carelessness 
of either dentist o'r patient. 

The Extent of Expansion and Contraction of amalgam is not un- 
der the control of manipulation by the operator, but is controlled 
by the composition of the alloy both as to materials used and their 
proportions; as well as the method of their preparation. 

The Flow of Amalgam under pressure is the term applied to the 
tendency of amalgams to flatten or move from under stress. 

Most metals will yield or flatten under a given stress in proportion 
to the load, up to a given point, and then cease unless the weight is 
increased. However amalgam continues to yield as long as the pres- 
.sure is continued even though it is not increased. 

This peculiarity in amalgam explains the phenomenon often ob- 
served in the mouth. Amalgams differ as to the amount of force 
necessary to produce flow, yet the peculiarity is exhibited by all 
amalgams. 

Edge Strength in a Filling is the term applied to the resistance 
a filling shows to stress upon thin margins at that portion of a fill- 
ing which covers the marginal bevel. 

Edge Strength in Amalgam. This depends first, upon the metals 
entering into the alloy. The greater the proportion of silver enter- 
ing into the amalgam up to seventy-five per cent, the greater the 
edge strength. Above seventy-five per cent it becomes more brittle. 
Second, the manner of packing. Third, the amount of actual union 
between mercury and alloy. Fourth, bulk at margin. 

The Maximum Strength will be obtained Avhen the alloy contains 
just enough mercury so that the mass will take the impression of 
the skin markings after prolonged kneading between the thumb and 
forefinger. Any more or less weakens the edge strength. 

The Length of Time the Alloy Stands has an effect upon edge 
strength, as amalgams made from alloys lose their edge strength pro- 
gressively with time, the more rapidly the higher the average tem- 
perature. 

However Aged Alloys Sliow Less Variations in Expansion, Con- 
traction and Range, and artificial aging is resorted to for this rea- 
son and is done by annealing. This annealing produces an amalgam 
that shows more uniform and consistent properties. 

Annealing of Amalgam is accomplished by subjecting- the alloy 
when freshly cut to either a dry or moist heat ranging from 110^ F. 



AMALGAM IN THE MAKING OF A FILLING 141 

to 212° F. for some hours or days. The lower temperature for a 
longer period produces the best results. 

Effect of Annealing. The artificial aging increases the contrac- 
tion, the flow, and the ability to withstand the crushing strain ; the 
amalgam requires less mercury, and sets slower. 

The Alloy Showing the Least Expansion and Contraction when 
unannealed is composed of seventy-two parts silver and twenty- 
eight parts tin and may be modified very slightly by adding a small 
per cent of copper or other metals. When annealed the above for- 
mula of silver tin alloy should be changed to seventy-six parts sil- 
ver and twenty-four parts tin, to get a stable amalgam. 

Cavity Preparation for Amalgam. Many of the failures in the 
use of amalgam attributed to the property of the material used are 
in fact due to laxity in cavity preparation, since many practitioners 
believe that thoroughness is unnecessary in this particular. The 
preparation of a cavity for the reception of amalgam is even more 
exacting than for gold, as the operator is dealing with a filling ma- 
terial possessed of a greater number of faults, each of which must 
be given consideration, and the cavity should be prepared in such 
a manner as to minimize these to the least degree. In compar- 
ing amalgam with gold it might be said that amalgam requires 
less access in awkward localities in the mouth, requires much 
separation in proximal fillings, and that the outline form must re- 
ceive more careful consideration as the margins must be farther 
removed from positions of great liability to caries, as well as stress. 

Flat Seats for Fillings are even more imperative than with gold, 
and the occlusal step must be broader bucco-lingually. The enamel 
walls must be finished with as great care, with a cavo-surface angle 
more acute, and a more deeply buried bevel angle. Cavities must 
have more retentive form. 

The Rubber Dam is very essential as it is imperative that amal- 
gam be built against dry, freshly cut, walls and margins. It is as 
impossible to make a good amalgam filling as it is a good gold fill- 
ing against moist walls. The residue from the saliva upon the walls 
will show leakage more quickly with the amalgam filling than with 
the gold. When operators come to the full realization of this fact 
and manipulate all amalgam fillings with as great care as gold, with 
reference to dry conditions, the frequent failures of amalgam will 
be materially lessened. 

The Matrix. All cavities filled with amalgam must have contin- 
uous surrounding walls. This will necessitate the adjustment of the 



142 OPERATIVE DENTISTRY 

matrix in cases where a wall is missing and applies to all Class Two 
cavities which reach the occlusal surface. 

The matrix should be thoroughly wedged at the gingival, to pre- 
vent excess contour at this point, and to secure additional space that 
contact point may be made close. It should be made of steel as thin 
as one one-thousandth of an inch. It should be made to encircle the 
tooth firmly either by ligating or by a retaining appliance, several 
of which are on the market. When two proximal fillings are to be 
built at the same time and in the same proximal space, two matrices 
are necessary, one for each tooth involved. 

However, better results are obtained, particularly with reference 
to proper contact restoration, by building up and finishing one fill- 
ing first, and then building the other filling at a subsequent sitting. 
By using a specially prepared matrix band of the proper size for 
the second filling, with a hole cut in the matrix to allow the metal 
to protrude at the point of contact with the first made filling, an 
ideal result may be obtained. 

Separation. Preliminary or iiuniediate separation is just as es- 
sential in the use of amalgam as gold. 

Making the Proper Proportions of Alloy and Mercury. Kach 
operator should test his favorite alloys and determine the exact 
amount of mercury for a given quantity of alloy, and by the use 
of a pair of balances be able to always mix in exactly the same pro- 
portions. By this means the operator is able to produce the best 
product by having the amalgam at its best. By the uniformity he 
becomes familiar with the habits of that particular alloy. 

This method need not be a time-loser, if the portions of alloy and 
mercury are previously i^ut up in separate capsules ready for im- 
mediate use. In early practice this can be done by the dentist him- 
self at leisure times and in after years by the assistant. 

Making the Mix. Upon the thorough incorporation of the mer- 
cury with the alloy prior to placing in the cavity depends much of 
the good qualities of an amalgam filling. Poorly mixed alloys have 
little strength. Amalgamation in an amalgam filling is never entirely 
complete, and while this process is going on, there is a certain 
amount of molecular action, which tends to change the form of the 
filling as a whole. A very great per cent of this union may be in- 
duced before placing the filling by a thorough preliminary mixing 
and kneading of the mass. 

To this end the alloy and mercury should be put into a wedgo- 
Avood mortar and thoroughly ground together till the contents seem 
to have become one mass. It should then be removed to the i>alm 



AMALGAM IX THE :\[AKIXG OF A FILLING 143 

of the hand and made into a pellet and then transferred to the thumb 
finger grasp and rolled between the fingers with sufficient force to 
produce a decided squeaking noise, sometimes spoken of as the ''cry 
of tin." Either too little or too much mercury will destroy this 
sound which should be sought. This kneading should be continued 
till the maximum plasticity has been secured, and the tendency to 
stiffen has just appeared. 

Wringing Out Excess Mercury. All surplus mercury should be 
expressed as soon as detected. With small masses this is thoroughly 
and quickly done by grasping the mass between the ball of the thumb 
and the tip of the first or second finger. The flesh of the fingers 
should entirely cover the mass from view. Then by a rocking mo- 
tion in which the mass is kept entirely covered the mercury svill 
appear from l)etween the fingers and not carry with it any appreci- 
able amount of the alloy. 

If the mass is too large to keep entirely covered during the proc- 
ess, it may be placed in a chamois skin and wrung to dryness, or di- 
vided into pieces sufficiently small to be manii)uhited with the fingers. 
As soon as the excess mercury has been expressed the whole mass 
should be again kneaded, as it should not be allowed to stand in this 
compressed condition. The mass should be rolled between the thumb 
and finger into a loose roi)e, broken into pieces, and laid in a posi- 
tion convenient to carry to the mouth. The rope or ball of amal- 
gam should never be cut with instruments, as that part close to the 
instrument is compressed and rapid setting facilitated. 

Amalgam Pluggers. The packing instruments should ])e as large 
as can be Avell used in the cavity, that the whole mass may receive 
the force of compression at each effort. The face of the plugger 
should be serrated to prevent slipping. A ball burnisher should 
not be used in packing amalgam, but is intended for finishing after 
the amalgam has set. 

Making the Filling. The cavity should be in complete readiness 
to receive the amalgam immediately after it has been prepared. The 
size of the portions will depend upon the orifice of the cavity, and 
should ])e as large as can be easily crowded into the opening. This 
should be immediately compressed upon the seat of the cavity with 
as large a plugger as possible, with a rocking motion and as much 
weight as the circumstances will permit. When using a point that 
is much smaller than the cavity, the same wedging principle used in 
packing gold should be employed ; that is, compress the central por- 
tion of the mass first and against the walls last. A burnisher should 
not be used ; neither should the burnishing nor wiping motion be used, 



144 OPERATR-E DENTISTRY 

but all compressing force should be directed at a right angle to the 
base wall. 

Quite a body of excess should then be added to the occlusal por- 
tion and a plugger point applied with mallet force which should be 
augmented with hard hand pressure. The hand pressure and mallet 
force combined will produce a more dense filling than by any other 
method and at the same time crowd the yet movable particles of amal- 
gam and alloy into closer adaptation to every portion of the cav- 
ity walls. 

Trimming Amalgam Fillings. After packing the amalgam it 
should be allowed to set undisturbed for one or two minutes, when 
the excess may be cut away with suitable knives. Gum lancet No. 
2 and the discoid and cleoid from the ' ' University set ' ' are service- 
able, as are also the large spoon excavators. 

Removal of Matrix. The matrix should then ])e removed in prox- 
imal cavities by drawing to the buccal while pressing the ball of the 
finger gently on the occlusal surface. A loosely rolled, rather large, 
ball of cotton should be laid on the amalgam filling under the finger 
tip, in order to prevent the matrix from traveling oeclusally in the 
process of removal. 

The rubber dam should then be removed and the patient instructed 
to slowly close the teeth, stopping the instant he feels the presence 
of the filling between the teeth, which will occur if excess contour 
has been built. With the teeth still held in this same position, the 
patient is requested to give the jaws a gentle side movement. This 
will result in burnishing the spots of contact, after which the excess 
should be whittled away with knife-edged instruments. 

Amalgam Should Be Cut From the Margins to the filling, which 
is just the reverse from the travel of the instrument in cutting gold 
fillings. If the cutting instrument moves from the filling to the cavo- 
surface angle with amalgam that is only partially set, it is liable 
to sink too deeply into the substance of the filling and expose the 
margin as it crosses over. 

Passing Contact Point. In proximal fillings of amalgam nothing 
of any description should ever be allowed to pass the contact point 
until the amalgam has completed the process of setting, as one such 
attempt forever destroys proper contact and a filling so treated be- 
comes at once a makeshift. All overhanging amalgam should be cut 
away, around the entire cavity outline, but the region of contact 
point should be entirely neglected at this time, and left for final 
shaping during the process of polishing. Finally the filling should 
be gently wiped with spunk or cotton. 



AMALGAM IX THE MAKING OF A FILLING 145 

Polishing. All amalgain fillings should receive as thorough and 
careful polishing as gold. This must be done at a subsequent sit- 
ting. In proximal fillings the separator should be adjusted and the 
contact point properly formed and polished. 

For this work abradents of onh^ the finest nature should be em- 
ployed. Burs, carborundum stones, coarse strips and disks only do 
harm and prolong the operation. Fine strips, disks, wood points 
and leather wheels, using first pumice then whiting, and lastly the 
tooth polishing rubber cups should be used. 



CHAPTER XXIV. 
THE I/SE OF CEMENTS IN FHLING TEETH. 

Varieties. There are five main varieties of cement available for 
use in the operation of filling teeth; silicate, cement, oxyphosphate 
of zinc, oxychloride of zinc, sulphate of zinc, and oxyphosphate of 
copper. 

Cavity Preparation for cement when the entire filling is to be of 
cement is not unlike that for any other filling, except that the cavo- 
surface angle is left the same as that produced by the cleavage of 
the enamel, omitting the marginal bevel. The ca^aty should be given 
the usual retention form, and the matrix must be employed in cav- 
ities to supply the missing wall that the cement may be introduced 
with pressure to condense and create close adaptation to walls. 

The rules given for dryness in the manipulation of gold and amal- 
gam are also to be observed in cement filling. 

The silicate cements have been evolved in an effort to produce a 
cement that would more nearly harmonize with the color of the 
teeth ; to better withstand the action of the oral fluids and the abrad- 
ing effects of mastication. Berylite is a prominent illustration of a 
silicate cement. Some of the silicates are now used as independent 
fillings and are not suitable for use as a cement. This material as 
a silicate filling is given full consideration in Chapter XXV. 

Oxyphosphate of Zinc has many uses in the cavities of teeth as 
a partial filling and in some instances for the complete filling. Be- 
ing a poor conductor, it makes an excellent agent as an intermediate 
between metal fillings and closely approached pulps. 

Its adhesive quality gives it great value as a means of adding re- 
tention to all kinds of metal fillings. This quality together with its 
harmonious color with tooth substance makes it invaluable for lin- 
ing weakened enamel walls which have lost much of their support- 
ing dentine. 

Its Chief Fault is its tendency to dissolve in the fluids of the 
mouth, which renders it comparatively temporary. However there 
is a considerable variation in its behavior in different mouths; in 
some instances it wears for years. 

Oxychloride of Zinc is indicated in pulpless teeth to fill the pulp 
chamber, after the canals have been previously filled with gutta- 
percha, and for the lining of cavities for the preservation of color 
where adhesiveness is not of importance. It is not indicated in 

146 



THE USE OF CEMENTS IN FILLING TEETH 147 

teeth with closely approached vital pulp, or as a root filling, on ac- 
count of its irritating properties. 

Sulphate of Zinc, when pure, is the least irritating of all cements 
and is one of the best materials for pulp protection. A pulp cap- 
ping of this material is of most universal application. 

Oxyphosphate of Copper is especialh^ indicated in remote cav- 
ities on the necks of teeth occasioned by gum recession. Cavities 
which are so ill-defined that the use of amalgam or gutta-percha is 
difficult, may be successfully filled with this preparation of copper. 

It can be made to adhere very tenaciously to the walls of a cavity, 
thus obviating much cutting. Oxyphosphate of copper is also in- 
dicated in the small cavities in the deciduous teeth. 

It is claimed that this material exerts a therapeutic influence up- 
on the tooth substance, thus preventing further decay. 

Manipulation of Oxyphosphate of Zinc Cement. The method of 
mixing this cement is not in the least difficult, yet certain details 
are essential. The slab, preferably of smooth glass, should be clean. 
The spatula should be flat with the side slightly convex. 

Agate is the best material as it is not acted upon by the liquid. 
The liquid and pow^der should be placed upon the slab separately, the 
drop of liquid being carried there by the use of a small glass rod. 
The spatula should never be immersed in the bottle to obtain more 
fluid as this Avould destroy the efficiency of the liquid. Crystallized 
portions should be carefully wiped ofP the mouth of the bottle as 
soon as detected. 

Plan of Spatulating. The powder should be added to the liquid 
a little at a time and each portion thoroughly rubbed by a swinging 
circular movement of the spatula upon the slab. This rubbing should 
not be rapid or vigorous. For lining cavities, where thin layers are 
desired which are very adhesive, the cement will prove correctly 
mixed when it shows slight stringiness and when the first stickiness 
appears, as shown by the slight resistance offered the spatula in its 
movement over the slab. Where the entire filling is to be of cement, 
more powder should be added and the spatulation continued till the 
cement materially resists spatulation and the mass is the consistency 
of freshly made putty. When cement is of the consistency desired 
no time should be lost in placing it in position, and it should be 
allowed to harden undisturbed. If the cement is to form the en- 
tire filling and permanency is desired, it should be crowded to place 
with some force and rapidly shaped up. As soon as crystallization 
begins it should not be disturbed by manipulation till it has fully 
hardened, when it should be polished with fine strips and disks. 



CHAPTER XXV. 

MANIPULATION OF SILICATE IN THE MAKING OF A 

FILLING. 

Definition. Materials for Silicate Fillings arc marketed under 
trade names which no douijt suit the purposes of the various manu- 
facturers, and there can be no just criticism offered from the stand- 
point of the tradesman. However some confusion exists among the 
members of the dental profession as to the correct term to use which 
is broad enough to cover all of this class of fillings and not desig- 
nate any special make. We will therefore consider some definitions 
from AVebster's "Unabridged Dictionar}'." 

Silicate (a noun) ''is a salt composed of silicic acid and a base." 
Silicate from which we make fillings is made by silicatization. 

Silicatization (a noun) "is the process of combining with silica, 
so as to change to a silicate," which is. chemically speaking, a syn- 
thetic process, — "the uniting of elements to form a compound." 

Porcelain (a noun). "A fine translucent kind of earthenware," 
named after the shell "Porcellana" "either on account of its smooth- 
ness and whiteness, or because it was believed to be made from it.'' 

Cement (a noun) when used as a noun is, "Any substance used 
for making bodies adhere to each other, as mortar, glue, etc." 

Cement (a transitive verb). "To unite by the application of a 
substance which causes bodies to adhere together." 

Cement (an intransitive verb).' "To unite or liecome solid: to 
unite and cohere." 

Cementation (a noun). "The act of uniting ])y a suitable sub- 
stance." Chemical definition: "A process which consists in sur- 
rounding a solid body with the powder of other substances, and heat- 
ing the whole to a degree not sufficient to cause fusion, the physical 
properties of the body being changed by chemical combination with 
the powder: thus iron becomes steel by cementation with charcoal 
and green glass porcelain, by cementation with sand." 

Enamel (a noun). "A substance of the nature of glass, ]>ut moi-o 
fusible and nearly opaque, — with a variety of colors: also otlier ma- 
terials iised for giving a highly polished ornamental surface." Ana- 
tomical definition: "The smooth, hard substance which covers the 
crown or visible part of a tooth, overlying the dentine." 

F]om the foregoing references to Webster it would seem that the 
term "silicate filling" is correct when used to name this kind of 

148 



SILICATE IN THE MAKING OF A FILLING 



149 



filling material as a class and when used to restore lost tooth sub- 
stance. 

The use of the word ''cement" as a part of the name, hence a 
noun, is incorrect unless the substance is used to ''make bodies ad- 
here together" and should be eliminated from the names of the 
silicates and other compounds intended for a filling per se, except 
when adhesive properties are taken advantage of. 

The term "synthetic" is correctly used when applied to any of 
the plastics now in use in dentistry, with a possible exception in 
amalgam, as chemists are divided in their opinions as to exactly what 
takes place in amalgamation. The use of the word "Porcelain" as 
a part of the name, its being correct or incorrect, depends entirely 





Fig. 79. 
Fig. 79. — Suitable cavitits for the use of silicate lillings. 



Fig. 80. 



Fig. 80. — A Class One cavity on the labial of a central incisor properly prepared for a 
silicate filling. The decays are shown in Fig. 79. 



upon our understanding of the degree of heat necessary to bring 
about cementation. (See definition.) This is accomplished at com- 
paratively low and ordinary temperatures with most of the makes. 
All are assisted in the process by temperatures slightly above that 
of the body, with one maker advising the melted paraffine bath dur- 
ing the period of setting. The use of the term "Enamel" is cor- 
rect provided it is a ' ' substance of the nature of glass, more fusible, 
nearly opaque, used for giving a polished ornamental surface," and 
the prefix of "Artificial" provided it is "a substitute" for the nat- 
ural covering of a tooth's crown. It would seem that the silicates 
are all synthetic, that they all partake of the nature of porcelain. 



150 



OPERATIVE DENTISTRY 



that they are a trade enamel, that they are artificial when replace- 
ing the lost enamel of human teeth, that they are cement 
when used to hold a filling of other material in the tooth or when 
the material itself adheres to the tooth, and that they are not cement 
(a noun) when used as a filling per se. 

The author therefore takes the position that the filling material 
under consideration is "silicate" as the correct manipulation of most 
makes eliminates adhesion to the cavity. Those which adhere to the 
cavity or will retain fillings of other materials in the cavity are for 
that reason a silicate cement. It therefore follows that with the use 
of silicate there must be retentive form in cavity preparation. At 





Fig. 81. 



Fig. 82. 



Fig. 81. — Extensive Class Three cavity properly prepared for a silicate filling. Decay 
shown in Fig. 79. 

Fig. 82.— A Class Five and a Class Three cavity suitable for the use of silicate as a tilling. 



this time we find the best illustrations of this class of silicate in ' ' De 
Trey's Synthetic Porcelain" and Ascher's "Artificial Enamel," 
neither of which should be used as a cement. 

Cavity Preparation is quite similar to that for an amalgam filling 
and is here considered in the order of cavity procedure. 

Gaining' Access. The access required for the silicate filling is the 
same as that for any other plastic filling, as far as its introduction 
is considered and the conditions sought at the time the filling is com- 
pleted. Contact point in Classes Two, Three and Four is just as 
essential, but is harder to maintain due to interproximal wear. It 



SILICATE IN THE MAKING OF A FILLING 



151 



would therefore follow that the primary contact should be greater 
and broader. In other words, if we are to use the marble contact 
it should be the contacting of larger marbles than in the more dur- 
able metal fillings. To put it in other words, the convexity of the 
filling's surface should be the segment of a larger circle than the 
metal filling. Proper separation is essential. 

Outline Form. In the consideration of outline form, the same 
rules should apply as when using any other filling. We should ex- 
tend cavity margins until all surface decay has been included. With 
other filling materials, we sometimes falter in this because of the un- 
sightly results, but with silicate, when the color has been properly 
chosen, there should be no hesitancy, as large fillings are generally 




Fig. 83. 



Fig. 84. 



Fig. 83. — A Class Five cavity properly prepared for a silicate filling. The decay is shown 
in Fig. 82. 

Fig. 84. — A Class Three cavity, lingual approach, properly prepared for a silicate filling. 
The decay is shown in Fig. 82. 



as little observed as small ones, especially on flat labial and buccal 
surfaces. When fissures and sulcate grooves are encountered, they 
should always be included in the outline, as a leaky filling will re- 
sult at the triangular space formed where the sulcate grooves meet 
the filling. 

Resistance Form. In dealing with resistance to the crushing 
strain, we have a greater problem to solve than in the use of almost 
any other material. The edge of the filling is more easily broken, 
and after some months or years of wear there is great danger of ex- 
posure of the cavo-surface angle. It is therefore necessary to lay 



152 



OPERATIVE DENTISTRY 





Fig. 85. Fig. b6. 

Fig. 85. — A small Class Three cavit}', labial ai)i)roach, proj erly prej ared for a silicate Hlling. 

Fig. 86. — A small Class Three cavitv, lingual approach, properlv prepared for a silicate 

filling. 





Fig. S7. 



silicate filling, 
times an ir- 



Fig. S7. — A large Class Three cavity, labial approach, properly prepared for a ; 
Note the irregular outline on the labial. This is not objectionable, for many 
regular outline hides a slight deviation from the proper color. 

Fig. 88. — A large Class Three cavity, lingual approach, properly prepared for a silicate 
filling. Note the fact that this cavity has two axial wails. This is a good form of preparation 
in vital cases. 



SILICATE IX THE MAKING OF A FILLING 



153 



the cavity outline in areas subject to as little stress as possible. 
In locations subject to great liability to stress, it is necessary to ex- 
tend the outline until full-length enamel rods, supported by sound 
dentine, have been reached and then beyond that to a location not 
subject to the travel of the cusps of opposing teeth in the process 
of articulation. It is not necessary to pay much attention to devel- 
opmental grooves, for when these grooves are normally formed they 
are fully as strong as the material in hand. It is most important 
that all enamel eminences be avoided, as the material is quite friable 
and offers very little support to the cavo-surface angle. 

Retention Form. Provision a,2:ainst the tipping strain is the 
same as for other fillings and is more like that for amalgam. This 




Fig. 89. 



Fig. 90. 



Fig. 89. — A large Class Three cavity properly prei)ared for a silicate tilling. Note the 
small amount of dentine yet remaining near the incisal angle. While this angle can properly 
remain when using a silicate filling, it would be entirely out of the question when using co- 
hesive gold. 

I"ig. 90. — Two extensive Class Three cavities ])ropcrly prepared for silicate fillings. In both 
of these cavities the dentine has been practically all removed at the incisal angles. Cases like 
these may be filled with silicate but should be regarded as temporary in a large majority of the 
cases. The retention of these angles after filling will depend entirely upon the amount of 
force to which they were subjected. They would be comparatively permanent in cases of ir- 
regularity when that condition placed these angles in a position removed from stress in oc- 
clusion and articulation. 



material only reaches its maximum strength to resist dissolution and 
the crushing strain when it has been so thickly mixed that it has 
lost practically all of its adhesive qualities. Therefore, the rules 
which apply to cavity preparation in reference to retention form 
would be the same as in the use of amalgam. We must have flat 
walls excepting the axial, flat seats of generous proportions and def- 
inite angles. 



154 OPERATIV-E DENTISTRY 

Convenience Form. This step in cavity preparation for the 
silicate filling, as with other plastics, comes in for only a minimum 
consideration, as it is seldom necessary in the use of this material 
to make any chajiges to facilitate the making of the filling, for when 
other rules have been followed we find ample convenience for its in- 
troduction. 

Removal of Remaining Decay. There is one major reason why 
all softened dentine should be removed from the cavity walls. The 
decalcified portion of tooth substance is always saturated with the 
acid of tooth decay, — lactic acid. Experience has proved that the 
crystallizing silicate will absorb this acid, resulting in a filling of 
weak structure. It would therefore follow that no softened dentine 
be allowed to remain in the cavity. 

Finishing of Enamel Walls. With otlier fillings it has been found 



Fig. 91. — A small set of instruments for manipulating silicate. 

advisable to bevel the enamel margins from 6 to 10 degrees centi- 
grade. With all silicate fillings, this beveling seems to make an ad- 
ditional Aveakness and should be avoided as it will cause the filling 
to break at the margin, even though the procedure results in an im- 
perfect cavity, from a scientific standpoint. We should determine 
that we have full-length rods and that we have found their direc- 
tion by complete cleavage and then omit the beveling. 

Toilet of the Cavity. To the ordinary toilet given for otlier fill- 
ings should be added the varnishing of the dentine walls, as a pre- 
caution against the material absorbing either acid or moisture from 
the walls or the absorption by drying dentinal walls of the fluid 
part of the filling, due to excessively desiccated dentine. 

Rubber Dam. The application of the rubber dam, or otlier means 
equally as efficient, should have taken place following partial outline 



SILICATE IN THE MAKING OF A FILLING 155 

form. Prior to adjusting the rubber dam, the color or combination 
of colors should have been selected, as the opinion formed after the 
rubber dam has been in place for a short time is worthless as a guide 
to the proper shade to be used. During the early experience with 
this material, with each operator, the shade guide should be fre- 
quently used as an educator, but in a few months, the operator should 
begin to be so familiar Avith the resulting colors that no shade guide 
is necessary. 

Making the Filling. When cavity preparation is completed, the 
proper material and instruments for making the filling should be 




Fig. 92. — A suitable slab and spatula for working silicate. The slab should be thick and 
heavy in order that when chilled it will remain at a low temperature during the mixing of 
the silicate. 

placed in a handy position. Absolute cleanliness is imperative, par- 
ticularly during the process of mixing, as otherwise the filling when 
completed will not be chemically pure. The mixing slab should al- 
ways be kept scrupulously clean, should not have a scratched sur- 
face and should be without color. This last point is to avoid any 
effect color could have on the judgment as to the shade desired. A 
good slab is produced by taking a large-mouthed bottle and filling 
it with cold water, or even ice water, in order that during manipula- 
tion the material may be held at a low temperature. Before using a 
thick glass slab (Fig. 92) chill to a temperature of 60 degrees or a 
little below. The temperature feature in this manipulation is of 
importance. With nearly all of the processes in the filling of teeth 
wherein the dentist depends upon subsequent chemical action for 



156 



OPERATIVE DENTISTRY 



a final result, chemical action should be either retarded or held in 
check during the entire process of manipulation, which is easily 
accomplished by a low temperature mix. ''The process of set- 




Fig. 93. — Proper position of the spatula on the slab when mampulatitig silicate. 




Fig. 94. — Proper placing of the materials when manipulating silicate. 

ting" as it is called is held in check until the material is finally in 
place and further disturbance unnecessary. As soon as the filliuir 
has been placed in the tooth, the warmth of the bodv is sufficient 



SILICATE IX THE MAKING OF A FILLING 



157 



to hasten the chemical action and better results will be secured. 
With most of the silicate lillings, the body temperature is suf- 
ficient ; with others the best result can only be obtained by keepins^ 




Fig. 95. — Taking the first portion of the pow<ler which should be about half of the cntii' 

amount needed. 




Fig. 96. — Incorporating the first portion of the powder. 

the filling for a short time l)athed in melted paraffine. The mix- 
ing slab should be at as low a temperature as possible and should not 
produce discomfiture to the patient. A temperature of 60 degrees 



158 operati\t: dentistry 

seems to be as low as can be borne by the patient when placing a 
filling in a vital tooth. It is therefore quite practical to use a 
bottle slab wherein the thermometer reaches 55 to 60 degrees, as no 
doubt the temperature of the filling is about 68 Avhen placed in the 
tooth. It is quite possible to use a bottle that contains iced water 
when the filling is to be placed in a non-vital tooth. At such times 
when the atmosphere is close to the dew point, as is evidenced by 
the condensation on the fountain cuspidor, there will be trouble 
about the formation of moisture on the cold bottle. When this is 
only slight, it does not seem to damage the filling. However, when 
the condensation is sufficient to be noticed, or is excessive, the den- 
tist has to either content himself with manipulation at a higher 
temperature or postpone the operation to a time when the atmos- 
phere is above the dew point. The spatula must be of some ma- 
terial which will give off none of its substance during the process 
of mixing. For this reason the agate is the best and most popular. 




Fig. 97. — Illustrating the circular motion which should be given the spatula in mixing a 
silicate filling. Note that the spatula should be moved first in one direction and then in the 
other as indicated by the arrows. Also that the spatula describes segments of small circles 
and that the material is not spread over any considerable surface of the slab. 

Begin the mixing onh^ when the cavity is prepared and dried, and 
the filling instruments are laid out and ready for immediate use. 
While there is no great haste as long as the material lays on the 
cold slab, there are left but a few seconds to make the filling after 
the material has been removed from the slab, on account of the 
rising temperature hastening chemical action. 

Preparing Materials. First pour out near the end of the slab to 
the right, the amount of powder the mix is liable to require, and 
then place stopper in the bottle. With the dropper place the 
proper quantity of liquid near and to the left of the powder. Im- 
mediately return the dropper to the bottle and secure the cap to 
prevent evaporation. The best results are obtained Avhen no less 
than three drops of liquid are used for the mix. Do not shake the 
liquid bottle. Make the mix promptly, for if there is any consider- 
able delay, the chemical formula of the liquid may be changed, due 



SILICATE IN THE MAKING OF A FILLING 



159 



to an evaporation in a dry atmosphere or the addition of water 
in taking up the condensation from the cold slab at low barometer. 
Making the Mix. Begin with sufficient liquid on the slab and do 
not add any more at that stage. Mix by draAving into the liquid 
about one-half of the total amount of poAvder required to make the 
completed filling. Begin the mix by spatulating with a light rotat- 
ing movement; hold the spatula fiat on the slab, describing the 
arc of a small circle with a diameter of say one-fourth of an inch. 
As soon as the powder has been all incorporated and the mass ren- 
dered uniform, scrape all of the mass off the slab with about three 
strokes. Take one-third of the mix each time. This assists in se- 
curing uniformity of the mass. Then put it back on the slab this 




Fig. 98. — The last stroke of scraping the iiiaterial from the slab. 

time getting all off the spatula. Do not scrape the spatula on the 
edge of the slab, but place it fiat on the slab, holding it firmly 
and giving it a turn in the hand, which will practically clean it. 
Here more powder is added, a small portion at a time, and incor- 
porated in the mass already mixed, by the method of crowding, 
which is done by rolling the spatula first against one side of the 
mass on the slab and then against the other. The addition of the 
powder by this crowding process is continued until the mass be- 
comes of a consistency of putty, losing practically all of its adhe- 
sion and giving only slight evidence of a tendency to follow the 
spatula from the slab. 

The Proper Consistency is reached when the mass has been mixed 



160 



OPERATIVE DENTISTRY 



SO stiff that the material just loses its gloss when being crowded by a 
rotating spatula, yet can be made to show a glossy surface when patted 
three or four blows with the spatula. In case the material looks very 
w^et and glossy, the mix is not yet stiff* enough. If the three or four 
blows do not produce gloss, the mix is too heavy and must be entirely 
discarded. 

Time of the Mix. The lower the temperature at which the sili- 
cate is mixed the longer may be the time of manipulation; also 
the thinner the mix, the longer Avill it be before the chemical ac- 
tion of the setting will be noticed. By using the cold process of 
mixing, the time of manipulation is lenprthened and the time of set- 




rig. 99. — The entire mix on the spatula. 




\ 




Fig. 100. — Illustrating in three successive steps the method of removing the mi.\ from the 

spatula to the slab. 

ting after leaving the slab is materially shortened, due to the thick 
mixture obtainable. 

Making the Filling. It is important that all moisture be ex- 
cluded, as we cannot manix^ulate silicate under moist conditions. 
Agate or ivory instruments are preferred for placing the material 
in the cavity. Those of bone or shell will do. If the instruments 
are absolutely clean and polished so that they will give off no sub- 
stance in the material, it is possible to place tlie silicate in the cav- 
ity with steel instruments and get no subsequent discoloration. 
Fill the cavity slightly to excess with absolutely clean instruments 
by taking a quantity, one-half of that I'equired to fill the cavity, 
and crowd or wipe the material against every portion of the cavity 
walls from cavo-surface angle to cavo-surface angle. The second 
time, take up a sufficient quantity to more than fill the cavitv. 



SILICATE IX THE MAKING OF A FILLING 



161 



Crowd this into position and hastily get a partial contour. Im- 
mediately pat or paddle the material to complete contour, continu- 
ing until the material has been crowded slightly over the margins. 
This paddling force will jar the material so as to bring back the gloss, 
as produced by patting on the slab. In case the gloss is not produced 
by the paddling, a homogeneous mass is not secured and the fill- 




Fig. 101. — Proper consistency of silicate, for immediate introduction into the cavitv. 




I-ig. 102. — This mi.x of silicate is yet too thin and there should be more powder added. 
The material should show a tendency to follow the spatula when moved from the slab but it 
should not follow the spatula as here shown. 

ing will lack proper color, Avill be of poor edge strength, and will 
make a very w^eak filling. If the gloss has been produced by the 
paddling or jarring of the material, it should be alloAved to remain 
undisturbed until the process of setting has sufficiently taken place 
that the body of the filling will not be moved by any work upon 
its surface. 



162 



OPERATIVE DENTISTRY 



The Use of the Matrix either upon the posterior or anterior teeth 
should be the same as that for the introduction of the amalgam 
filling. With Class Three fillings, one end of the matrix is left 
loose until the cavity has been filled more than full with the ma- 
terial. The loose end is then brought over the tooth and tapped on 
the outside of the surface as it is being tightened upon the filling. 
This jarring process of bringing the matrix to position results in a 
homogeneous mass beneath the matrix. Immediately after pad- 
dling the filling and the detection of the glossy surface, the filling is 
to be entirely coated with cocoa butter to exclude the air during 
the process of setting. 

Finishing the Filling. After the filling has been allowed to stand 
undisturbed for three or four minutes (no longer), there should be 
applied a very thin-edged knife or chisel and by a scraping motion 




Fig. 103. — A homemade mallet and point used by the author in iiaddlir.;. ^ 

silicate to position in the cavity. The mallet should be of light weight and have a >uit sur- 
face. The plugger point here shown is made of platinized gold. Tandilum would be better 
for this provided it had a handle attached which was of very light material. It is quite neces- 
sary in this process that both hammer and plugger point are of the least possible weight. 



parallel with the cavity outline the excess is cut away to within 
one-tenth of a millimeter of the cavo-surface angle, at the same 
time reducing the general contour to that desired, keeping the 
filling submerged in the cocoa butter. When the filling has been 
in position five or six minutes, very fine strips or disks coated with 
cocoa butter may be used to produce the desired gloss. The author 
prefers to leave the filling with file and knife finish and has aban- 
doned the use of strips and discs as iniurious. This completed 
filling should be scrubbed Avith cotton balls in order to remove all 
of the cocoa butter possible and the finished filling painted with a 
copal-ether varnish. No varnish of which alcohol is a part should 
be used. Evaporate to dryness with air, remove the rubber dam 
and test for occlusion and articulation, provided the filling in- 



SILICATE IN THE MAKING OF A FILLING 



163 



volves the occlusal or incisal surfaces. In case the filling is found 
to strike the apposing teeth, the excess should be ground off with 
fine carborundum wheels, and again varnished. It is entirely safe 
to use carbon paper to print these fillings, the same as with gold 
or amalgam and its use will not cause discoloration of the filling. 
The instruments used in reducing the size of silicate fillings should 
be the same as when reducing the bulk of a gold filling. The 
manufacturers of some of the. silicates advise not to use any steel 




Fig. 104. Fig. 105. 

Fig. 104. — Three cavities suitable for silicate fillings. 

Fig. 105. — This shows the results obtained after filling with silicate the cavities shown in 
previous figure. 

instruments in the finishing of these fillings, but clinical experi- 
ence has proved that any injury which can result is not due to the 
instruments, but to their unclean condition. 

Facing Metal Fillings with silicate is many times of advantage 
and is at this time the only method wherein it is advisable to use 
silicate in connection with angle restoration in Class Four fillings. 
This will be more fully discussed in Chapter XXVIII dealing with 
Combination Fillings. (See Figs. 106, 107 and 108.) 



CHAPTER XXVI. 
THE USi: OF GUTTA-PERCHA IX FILLING TEETH. 

Gutta-Percha has its place in various operations upon the teeth. 
It is not acted upon by the fluids of the mouth and is quite 
permanent when placed in locations protected from the force of 
mastication. 

It is a good tooth preserver as decay does not readily take place 
in cavities so filled. 

Base Plate Gutta-Percha is tlie best form to l)e had. It comes in 
the Avhite and pink colors, the last named ])ein«: the most dur- 
able in i)ositi()ns exposed to wear as it gets the harder upon cooling. 

Filling Cavities with Gutta-Percha. This material is indicated 
in subgingival cavities, both buccal and proximal, where a fill- 
ing that is a very poor conductor of heat is desired, on account of 
close proximity to the pulp, the \m\\) being not yet exposed. 

it is also indicated for those disti-essing cases where there is a 
decay started in the occlusal surface of a lower third molar which 
has erupted Avith its occlusal surface at an angle of about forty- 
five degrees to the distal of the second molar. Such cases cannot 
as a rule be properly extended to check decay in the use of amal- 
gam or gold. 

The gutta-percha filling will chock decay and if renewed at 
stated periods will produce sufficient separation for correct filling 
or to render extraction easy. 

Method of Preparation and Filling. The cavity should l)e freed 
of all decay and the cleavage of the enamel secured, omitting the 
marginal bevel. The cavity should be sterilized and dried, then 
slightly moistened with campho-phenique or euealyptol. The 
gutta-percha should then be warmed and immediately crowded to 
position. Care should be taken that the material is not overheated 
as slight burning destroys the durability of rubber. 

The gutta-percha should be introduced piece by piece sufficient 
to a little more than fill the cavity. The surplus must be wiped off 
flush with the cavity margins Avith warmed burnishers. Finally 
the surface should be Aviped Avith a cotton ball carryinsr chloro- 
form. 

For Root Canal Fillings. The guttn-i>ercha is dissolved in chloro- 
form to the consistency of molasses, and carried to the canals by 



GUTTA-PERCHA IX FILLING TEETH 165 

dipping a smooth broach in the container. The canals should have 
been previously flooded with oil of eucalyiDtol, and the chlora- 
percha mixed with the eucalj^ptol in the root canal resulting in 
Avhat may be termed euco-percha. The eucalyptol may be added 
to the chlora-percha in the bottle, but the method given first is for 
various reasons the better. 

For Canal Points. Gutta-percha is the standard material for 
canal poiiits which should be at hand in various sizes to suit all 
cases. 

These may be manufactured ])y the dentist, but Avith little econ- 
omy, as they are Avell made by macbinery. Those which are flat- 
tened on the larger end are the most handy to use. Such may be 
had from your dealer, or the assistant can flatten them as pur- 
chased by placing them on a glass mixing slab and pressing each 
large end Avith a smooth cold steel instrument. 

Slow Separation. Gutta-percha for slow separation in proximo- 
occlusal cavities is unexcelled, the force of mastication doing the 
work slowly but surely. This fact prohibits the use of gutta- 
percha as a permanent filling iii Class Two cavities. 

Temporary Stopping, as purchased from the dealer, is gutta- 
percha to Avhich wax has been added to render it more plastic 
when warmed. This is ideal for sealing in dressings, excepting 
"when arsenic has been used, in which case pooi'ly mixed amalgam 
is better. 



CHAPTER XXVII. 

' TIN AS A FILLING MATERIAL 

History. The first use of tin as a material for filling teeth would 
seem to date back to about 1780 and was much written about as 
a tooth preserver for the century following. After the introduc- 
tion of amalgam in 1826 there seemed to have been much rivalry 
between the two substances, amalgam gaining the favored position. 

At the World's Columbian Dental Congress, in Chicago, 1893, as 
will be seen by the report, many dentists of national repute Avent 
on record as classifying tin as one of our best tooth savers and de- 
plored the fact that its value Avas being lost sight of. 

The late Dr. W. C. Barrett expressed himself so empliatically as 
to say, ' ' Tin is as cohesive as gold, and if everything were blotted 
out of existence with which teeth could be filled, except tin, more 
teeth would be saved." This may be putting it a little too strongly, 
but the fact remains that more teeth would be permanently saved 
if a more general use of tin was common with the profession today. 

Therapeutic Value of a Tin Filling. Of all our filling materials 
there are only two for Avhich any therapeutic value is claimed. 
All others prevent the farther loss of tooth substance by exclusion : 
mechanically shielding the defenseless tooth substance from the 
dissolving properties of the products of fermentation. 

The Therapeutic Action of Tin is probably due to the formation 
of the sulfid of tin which is caused by the presence of sulfuretted 
hydrogen from the decomposition of food substance. The dentinal 
w^alls of a cavity which has been filled with tin for some time, turn 
brown or black and seem to have undergone a structural change 
rendering them quite impervious to decay, and very hard to ex- 
cavate with hand instruments or the engine bur. 

Discoloration. In some mouths tin turns black not only upon 
its external surface but this color is in a measure transmitted to 
the tooth substance, a fact Avhich is one of the greatest objections 
to its use and debars it from exposed jH^sitions in the anterior por- 
tion of the mouth. In other mouths there seems to be little dis- 
coloration, the filling remaining polished and of a light color. 

The Amount of Discoloration seems to bear no relation to its 
permanency as to bulk or as a tooth preserver. 

Thermal Conductivity. Tin is only one-fourth as good a oon- 

166 



TIN AS A FILLING MATERIAL 167 

ductor of heat as gold, hence, indicated under gold fillings in deep- 
seated caries with vital pulp. 

Indicated in Rapid Caries. In caries of a light or white color 
indicating the most rapid form of decay, tin is of peculiar advan- 
tage, particularly in regions removed from view and protected 
from the wear of mastication. 

Tin in the Teeth of Children. There is no better material for fill- 
ing the teeth of children than tin. The principle of mechanical ex- 
clusion depended upon with other filling materials to prevent re- 
current decay does not seem to be sufficient in the rapid form of 
decay met with in both temporary and permanent teeth in the 
mouths of children particularly during the age of rapid develop- 
ment as found before the age of fifteen or sixteen. The additional 
advantage of the therapeutic influences of tin seems to be sufficient 
to check this rapid progress of decay till a period is reached when 
the process of tooth destruction is less apparent, due to more hy- 
gienic conditions in the oral cavity. 

Cavity Preparation for Tin. The cavity preparation for the use 
of tin is not unlike that given in the chapters on cavity prepara- 
tion b}^ classes for cohesive gold. It will be of advantage if the 
convenience angles are a little more distinct, and the general re- 
tentive form throughout should be emphasized. The bevel angle 
should be a little more deeply buried as the edge strength is not 
as good as hammered gold. However the edge strength is better 
than amalgam. Tin has no tendency to spheroid like amalgam. 
Its flow is similar to that of gold but greater with the same given 
load and like gold it is capable of being so condensed that it will 
stand repeated stress of a given load within a limited range and 
show no flow. 

Forms of Tin. Formerly the only form of tin to be had for this 
purpose was the sheet tin. This was manipulated in much the 
same way as cohesive gold except that it required no annealing. 

It was then, and is yet, sometimes combined with gold by rolling 
a sheet of pure tin with a sheet of annealed cohesive gold into 
rolls, the gold on the outside and condensed in the usual manner 
using a large proportion of hand pressure. 

At present there is on the market a form of tin prepared in the 
shreds, which appears like a mass of coarse silver-colored hair. 
This is removed from the tube and shaped into pellets of suitable 
size and placed in the cavity in the manner one would place pellets 
of gold. 

Methods of Introduction. The rubber dam or other efficient 



168 OPERATIVE DENTISTRY 

means of dryness must be used. AVhen one of the surrounding 
avails is missing as in proximo-occlusal cavities in bicuspids and 
molars (Class Two) the matrix must be in place. The first pellet 
of tin introduced should completely cover the base of cavit}' and 
be thoroughly condensed by good steady hand pressure, Avith 
points at least one square millimeter in size employing the rock- 
ing motion. The points should have deep serrations and be so stepped 
as to include the entire surface. 

This hand pressure should be followed with the mallet force 
using a plugger point of medium serrations and the surface en- 
tirely gone over. A new pellet may now be applied and the plan 
just given repeated. If the lilling is to be entirely of tin the cavity 
should be filled to excess and by a process of burnishing, con- 
densed and rubbed to the size desired. This last method gives a 
surface of the greatest density possible. 

Tin and Gold. AVhen the filling is to be completed Avith cohesive 
gold little dependence should be put upon the gold adhering to the 
tin as the union is only slight. AVith a round-pointed instrument 
new convenience angles should be nmde in the substance of the 
tin near the line angles. The remainder of the cavity should be 
retentive independent of the space occupied by the tin. 

Tin and Amalgam. No special care is needed Avhen the filling is 
to be completed Avith amalgam. Amalgamation takes place in that 
portion of the tin next to the amalgam proper and the union is 
quite strong, even more than tin to tin. The amalgam should, if 
possible, be more thoroug?dy mixed and the process of kneading 
prolonged that all amalgamation possible be secured before con- 
tacting Avith the tin as the tin Avill take up some of the mercury 
from the amalgam for Avhich it has a great affinity. This is liable 
to injure the amalgam as to strength unless the mixing has been 
thorough. The use of tin and amalgam is not advised Avhere the 
surface of the tin is to be exposed by forming any portion of the 
contour as the presence of the mercury absorbed causes the tin to 
rapidly disintegrate. Gold should be used for topping in such 
cases. 

Tin in Bifurcated and Punctured Roots. When throush decav 
or by accident the caAdty extends to the exposure of the peridental 
membrane the use of tin has no substitute. The opening should 
be rendered as clean as possible, sterilized and dried. The vipen- 
ing should be covered Avith a mat of pure tin made from foMed 
sheets, being lightly burnished to place and covered Avith amal- 
gam and the cavity finished Avith the desired material. 



CHAPTER XXVIII. 
COMBINATION FILLINGS 

Definition. A combination filling is a filling composed of two or 
more distinct substances introduced into the cavity separately. 

Objects of a Combination. The object of combining various ma- 
terials in the filling of a tooth's cavity is to secure a perfect fill- 
ing, one possessed of all virtues, and no faults. Many such com- 
binations of material meet this demand in a large measure by 
bringing into service the strong features of each material, and at 
the same time nullifying the faults of all material entering into the 
construction. 

Since dentistry has been raised to the dignity of a science there 
has been a diligent search to discover a filling material which pos- 
sesses the virtues of all and the faults of none in present use. At 
the present time this is more nearly reached by the various com- 
binations possible with the usual distinct materials. If perchance 
the ideal filling is ever produced, dentistry will at once become 
much simplified as to methods of procedure. 

Single Materials Used as a Filling. There are only two filling 
materials now in use which are used in their pure state, pure gold 
and pure tin, and there are many instances where these combined 
with each other or with other materials, will produce better results 
than when used alone. 

Gold and Tin Combination. This combination is of service in 
large cavities of Class Two which are subgingival and in large 
occlusal cavities in molars, Avhere the pulpal wall is deep and 
rounded. In this combination the tin should be placed in the cav- 
ity first and thoroughly condensed, and the filling completed with 
cohesive gold. 

In Class Two the tin should cover the gingival wall at least one 
millimeter deep and be condensed to place with the matrix in 
position. 

Benefits derived. Dentine upon which has been built a thor- 
oughly condensed tin fillins: does not readily decay. Bv com- 
pleting the filling Avith gold the discoloration of tooth substance 
is avoided and the gold will better resist the force of mastication. 

Gold and Cement. The object of this combination is to produce 
a filling that is adhesive, will protect Aveak walls, and resist the 
fluids of the mouth and the force of mastication. 

169 



170 OPERATIVE DENTISTRY 

Two Methods of Combining'. There are two methods of produc- 
ing this combination. One is to cast the filling and lay it into the 
cement-covered cavity, which is the inlay method. The other is 
to build cohesive gold into a thin mix of soft cement with which 
the walls of the cavity have been coated. The essential feature of 
both is that the cement be completely covered to protect it from 
dissolution by external agencies, as the fluids of the mouth and the 
effects of wear. 

When Indicated. The inlay combination is indicated in large 
cavities of easy access. The built-in method of combination is in- 
dicated in small cavities of more difficult access, and where cor- 
rect cavity formation is impossible or ill-advised. When using 
this method convenience angles may be omitted. 

Gold and Platinum. This combination adds to the many virtues 
of cohesive gold fillings by increasing the resistance of the filling 
to the wear of mastication. The pure gold is first used as it is capa- 
ble of more perfect adaptation to the walls, all of which should 
be covered before taking up the platinized gold. The contour por- 
tion should be made of the alloy. This alloy comes from the sup- 
ply house in sheets which appear to be pure gold except that the 
color is a little lighter. This foil comes in three numbers, 1, 2 and 
3, the No. 2 being preferable for most cases. 

The rules for condensation are just the same as for pure gold, 
only the observance of each specific rule given on that subject is 
more emphatically demanded here, and when strictly followed the 
alloy will prove as easily handled. 

Cohesive Gold and Non-Cohesive Gold Combined. By this com- 
bination much time is saved as the non-cohesive gold may be in- 
troduced in greater masses than the cohesive. Also the soft gold 
is more easily adapted to the walls than cohesive. 

The cohesive gold is used to finish the contour as it will better 
resist the torsion strain and the effects of abrasion. Before the 
introduction of cohesive gold all gold fillings were non-cohesive, 
but since the introduction of the former the art of filling teeth 
well with soft gold has rapidly declined, so that the making of an 
entirely non-cohesive gold filling is now the exception. 

Cement and Amalgam. Results similar to what might be termed 
an amalgam inlay are produced by coating the prepared cavity with 
cement, and immediately burnishing into this fresh cement, a por- 
tion of the amalgam. The enamel margins are rendered clean 



COMBINATION FILLINGS 171 

again by freshly cutting them with a chisel for their entire outline 
and the amalgam filling immediately finished in the usual way. 

The Benefi.ts. This combination produces a filling with the vir- 
tues of an amalgam to which is added the adhesion of the cement 
and the protection of cavity wall from fracture and discoloration. 

When Indicated. This is indicated in most large cavities to be 
filled with amalgam, where the Avails are weak and thin and in 
cavities where insufficient retentive form is secured. 

Cement and Porcelain. Cement is combined with porcelain in 
the filling of teeth for the purpose of making the filling adhere. 
The porcelain protects the cement from dissolution. 

Silicate Cement and Fused Porcelain. Fused porcelain inlays 




Fig. 106. — Combination gold inlay and silicate. A represents the gold inlay in position 
ready to receive the silicate. B represents the same after the silicate has been put in place. 

may be set with some of the silicate cements to great advantage. 
The silicate filling materials which are at their best when mixed 
thin enough to be adhesive are those which can be used as a ce- 
ment. In fact some operators are using these materials for setting 
the gold inlay with seemingly good results. 

Silicate and Gold. Silicate may be used to face the gold filling 
for esthetic reasons. In filling Class Four cavities with the gold 
inlay, by either one of the four plans, the wax may be cut out of 
the pattern so as to present a labial surface almost entirely of 
silicate. After these two materials are combined in this class of 
cavity, care should be taken that the incisal edge is of gold and 



172 



OPERATIVE DENTISTRY 



particularly that the cavo-siirface angle on the incisal outline is 
protected by one-half of a millimeter to a millimeter of the cast 
gold. The cast should be made and set with oxyphosphate of 
zinc cement. Al a subsequent setting the silicate face may be built 
in. A similar effect is produced with the bicuspids and molars, in 
crown work. The gold crown is made in the usual way and set. 
A carborundum stone is applied to the buccal surface and ground 
away and a sufficient amount of cement cut out to make room for 
the building in of the silicate. Before building in the silicate it is 
best to coat the cement which is exposed within the crown with a 
thin application of copal-ether varnish. 

Silicate and Amalgam. ]\raiiy large contour amalgam fillings on 
the mesial surfaces of bicuspids and molars particularly in the 





Fig. 10/' 



Fig. 107. Fig. 108. 

-Amalgam in position ready to receive a partial facing of silicate. 



Fig. 108. — This represents the amalgam filling shown in Fig. 107 with the silicate facing 
built in. The dotted line shows the outline of the silicate with that portion marked .r, repre- 
senting the silicate. 



superior teeth are unsightly. A very pleasing effect is produced 
by cutting away the mesio-buccal contour of amalgam, either in 
new or old fillings, and in the resulting cavity, build silicate. The 
silicate will not discolor when thus applied to the amalgam. Hoav- 
cver, each individual case seems to require a different shade and 
to get it right a trial mix shoidd be made before decidinir (^n the 
combination of powder to produce the desired shade. 

Silicate as Applied to Prosthetic Work. It is not within the 
scope of this book to deal with prosthetic procedures. However, 
it is well to call attention to the fact that this material is used to 



COMBINATION FILLINGS 173 

advantage in the facing of crowns, the fitting of gingival ends of 
porcelain pin crowns to the root, and its application to many 
places in pieces of bridge work. It is also useful in the facing of 
partial and full removable dentures in a color to imitate the 
natural gum tissues. 

There are many other combinations which are made and used 
to advantage in tooth salvage. It is improbable that the perfect 
filling material Avill ever be produced as the demands are so varied 
in different mouths, and in different localities in the same mouth. 

We are more nearly able to meet all of those varying conditions 
by a wise selection of the materials to be used in each case and a 
judicious combination will go far to produce the perfect filling for 
each individual cavity as presented. 



PART III 

CHAPTER XXIX. 

EXAMINATION OP THE MOUTH LOOKING TO 
DENTAL SERVICES 

The First Duty of a dentist to one presenting himself for dental 
services is to comply with the patient's request, which is generally 
to examine a special tooth or a diseased condition of which the 
patient is aware. If the patient does not make such a special re- 
quest it is well to ask some form of a leading question as to the 
reason of the call. This fact elicited, all else should be ignored 
until the object of the first visit has been accomplished. 

A Light Hand and Slow Movements are very essential for the first 
few moments, especially at the first meeting of patient and dentist, 
as first impressions are often lasting and if the stranger is ap- 
proached in a careless manner he may get ideas of undue rough- 
ness, many times unfounded, yet, nevertheless, lasting with the 
nervous patient. 

The Washing of the Hands in the patient's presence or in run- 
ning water within hearing of the patient should be universally 
practiced no matter if the operator knows his hands to be already 
scrupulously clean, as it assures the patient that the operator has 
a regard for at least the simpler forms of cleanliness. 

The Linen Upon the Chair should be inviting and unsoiled. If 
convenient, it is well that the patient see tliat which is already on 
the chair changed for fresh. 

Few Instruments should be in sight, as they serve to remind the 
patient of former experiences not always pleasant. 

After the First Requests of the patient have been complied with 
it is well to take a rather general survey of the mouth before an- 
swering many questions regarding the advice to the patient as to 
future procedures. The operator should note in this ''bird's-eye 
view," as it were, the probable care that is being bestowed upon 
the teeth and mouth in a prophylactic way. Also the health of the 
soft tissues, the number of extracted teeth, the presence of den- 
tures and amount of dental work previously done, noting its qual- 
ity and probable age, as well as the number of badly decayed teeth 
yet unfilled. He should note the health of the patient, probable 

174 



EXAMINATION OF MOUTH LOOKING TO DENTAL SERVICES 175 

age and habits. All this can be done at a glance and in a few 
second's time, when the operator will be much better qualified to 
advise the patient as to what is best to do in a special case. 

If the Patient Is in Pain its alleviation is of first importance and 
should receive immediate attention. It may require the applica- 
tion of medicinal remedies, or some mechanical procedure or even 
the extraction of a tooth, but, whatever it may be, it must be done 
at once as the patient is in no mood to receive sage advice about 
the future when he is at present in pain. 

Early in the Examination Sitting the patient should be advised 
of the necessity of a prophylactic treatment provided the teeth 
and mouth are not scrupulously clean, Avhich is seldom the case, 
unless the patient has recently visited the dentist for that purpose. 

This Is Second Only to the relief of pain and it is manifestly the 
dentist's duty to attend to prophylaxis before proceeding to the 
making of fillings. 

A Careful Examination should be suggested, follo^^'ing the hasty 
inspection, and, if advised to do so by the patient, the dentist may 
then proceed to search all surfaces for the various classes of decaj^, 
not forgetting the vulnerable points about work previously placed, 
as the margins of fillings and about the bands of crowns. 

The Instruments Needed are, a clear, uninjured mouth mirror, a 
sharp pointed instrument called an explorer , cotton pliers and 
small balls of absorbent cotton, waxed floss silk, chip blower and 
mechanical separator. A small electric mouth lamp is also of value. 

The Use of the Mouth Mirror is to see therein the image of sur- 
faces and locations where direct vision is imperfect or impossible 
and to flood the point being examined with an abundance of light. 
Many cavities existing in the proximal spaces are not noticed until 
strong rays of light from a different angle than the line of vision 
of the examiner have been directed against them. 

The Use of the Explorer is to note the extent of decalcification 
at suspected points and the inspection of pits and grooves for 
faults in enamel. This instrument should be in the shape of an 
elongated cork screw turn, that the more inaccessible points may 
be reached. A light hand in its use is imperative as the dentist 
is not excused for breaking dovv-n tooth substances or for causing 
much pain in any of the processes of examination. 

Absorbent Cotton in the pliers is used to take up the moisture in 
cavities of considerable size and whose depth questions proximity 



176 OPERATIVE DENTISTRY 

to the pulp ; also sensitive surfaces suspected in shallow cavities, 
particularly those in the gingival third. The cotton balls should 
not be too large and rather tightly rolled. 

Waxed Floss" Silk is used to examine the proximal space where 
the reflection of light does not make diagnosis positive. It cleans 
the surfaces of debris and food particles, giving a deeper insight 
from the embrasure. AVhen surfaces are roughened or cupped from 
incipient caries, it will show by the catching or cutting of the fibers 
of the thread ; if the surfaces still retain their normal polish the 
thread will pass uninjured. 

The Chip Blower is a small hand ])ellows for the expulsion of air 
and is used in examination of the teeth to blow away and evaporate 
the moisture from points where it is held by capillary attraction, 
giving, thereby, a better view and a more correct idea as to the 
color present, which is a strong factor in a diagnosis of conditions. 

The Mechanical Separator will sometimes be of service to "rain 
a little added s])aco for the inspection of contacting surfaces. 

The Use of the Electric Lamp on the lingual side of the teeth has 
many advantages and is a speedy and sure way of detecting any of 
the stages of caries in the proximal spaces, the vitality of a tooth's 
pulp as well as abnormal conditions about the alveolar wall and the 
presence of pus and inflammatory changes in the maxillary sinus. 

When the Examination Is Completed the patient should be ad- 
vised of the true condition of his mouth, including the indicated 
treatment of both hard and soft tissues. If the patient indicates 
a desire to have the services rendered as outlined by the dentist it 
is entirely good business, and by no means unprofessional, to ap- 
prise the patient of the probable cost of the work as planned when 
it can be approximately estimated, unless the patient is a frequent 
visitor and familiar with the charges expected from the dentist con- 
sulted. 



CHAPTER XXX. 
THE ALLEVIATION OF DENTAL PAINS. 

The First Duty of the Dentist is to relieve suffering, and as in 
many instances this is the reason for the first call of the patient it 
is most essential that the relief sought is obtained. Many times the 
relieving of a paroxysm of pain by the dentist has made a lifelong 
friend and patient. 

The Diagnosis is a most vital point and the battle is half won 
when this is correctly made. 

Pay Strict Attention to What the Patient Has to Say as he is 
quite sure to give you his symptoms in the order of their prominence 
and it is generally the prominent symptoms that are pathognomonic. 

After the Patient Has Given the Most Aggravated Symptoms, 
make an examination of the afflicted part of the mouth to verify the 
statements made. If all is not clear quiz him more specifically. Do 
not jump at conclusions. The patient is generally right as to symp- 
toms but frequently wrong as to location and cause. These last are 
the points the dentist must decide, as well as upon the treatment for 
relief. 

There Are Two Divisions of Dental Pains, those arising from 
lesions of the tooth pulp, and those arising from degenerative changes 
in the sulxlental tissues, which are generally the sequelae of the same 
destructive processes in the pulp. They may follow the pulp troubles 
or occur simultaneously with them. 

. Pulp Lesions. Symptoms are sensitiveness to thermal changes. 
The tooth is not necessarily sore to percussion. Pain is increased 
or induced Avhen assuming a recumbent position. The presence of 
foreign substances in the tooth cavity cause pain especially when 
pressed against the walls of the cavity. Pain comes in paroxysms 
with a tendency to intermittence. Patient may complain of ''jump- 
ing toothache." These symptoms may all be present in the same 
case or only one at a time in the series of changes that take place 
in a pulp from the initial affection to its death. 

The Treatment for Speedy Relief is varied according to the most 
prominent symptoms, as these are the indications of the stage of dis- 
solution. 

If Cold Air or Water Causes Pain of a quick, sharp, shooting na- 
ture, comes on suddenly and passes off immediately upon the tooth 
regaining the bodj^ temperature, the pulp is in the stages of active 

177 



178 OPERATIVE DENTISTRY 

hyperemia, which is the initial stage of a destructive disease, and 
will respond immediately to the application of anodyne and effectual 
protection froiji air and fluids, which is accomplished by stopping 
the cavity with a non-conductor, generally cotton, or temporary stop- 
ping, or an application of phenol. 

If Warm Fluids Cause or Intensify the Pain and the application 
of cold relieves the pain temporarily, the pulp will be found to be 
well advanced in the stages of dissolution, some portion of which 
has been resolved into the end products. Gaseous substances oc- 
cupy portions of the pulp cavity, which is closed over the entire 
coronal portion by a layer of dentine, a filling or a plug of foreign 
substance. These gases are expanded by the elevation of the tem- 
perature, causing increased pressure upon the remaining vital por- 
tions of the pulp and intense pain results, which is further aug- 
mented, many times, by the pulsations of the heart. The pulsating 
symptom in this instance indicates that quite a portion of the pulp 
is yet vital. 

The Treatment for Relief in This Case, ^vhich is called closed 
putrescence, is the removal of the obstruction for the escape of the 
gas. This involves opening into the pulp chamber through the route 
of the least obstruction or injury to the tooth. Necrotic portions of 
the pulp should be removed, disinfectants and anodynes applied and 
devitalization of the remaining vital portion effected. 

If Moderately Warm Fluids Cause Pain as well as cold tlie pulp 
is in the first stages of passive hyperemia or congestion. This con- 
dition is generally soon followed by the symptom of being more pain- 
ful upon the patient's lying down and the throbbing pains setting 
in, and many times patients will say, **I have the jumping tooth- 
ache;" or, ''It began last evening about fifteen minutes after I went 
to bed." 

Treatment of Passive Hyperemic Pulp for relief is sterilization 
of immediate surrounding tissue at the tooth's cavity and the ap- 
plication of sedatives and anodynes. If the pulp can be bled with 
causing but slight pain it is beneficial ; then proceed to devitalization. 

The Painting of the Gum Avith a revulsive is of service, especially 
if the pericementum is taking on the stages of inflammation indi- 
cated by slight soreness to percussion. 

If the Presence of a Foreign Substance in a cavity causes pain it 
may be an exposed pulp which is not very highly organized, or hyper- 
sensitive dentine covered Avith a layer of leathery decay. 

The Treatment Is the Removal of the offending object and the 
prevention of its recurrence by temporary or permanent stopping. 



ALLEVIATION OF DENTAL PAINS 179 

Pericemental Diseases Causing Pain have for their most path- 
ognomonic symptom the soreness to percussion, as shown by gently 
tapping on the occlusal surface of the tooth with a steel instru- 
ment. Slight swelling of the pericementum causes the tooth to ap- 
pear to the patient as much elongated and the patient will generally 
make such remarks as these, "I have a sore tooth;" ''It hurts to 
close my teeth ; " " My tooth is too long, ' ' etc. 

If the pulp is entirely dead, and removed, or there is not a case 
of enclosed putrescence, thermal changes will have no effect, except 
in rare cases warmth applied to the parts will give a slight sense of 
relief. 

Treatment for the Relief of Pericemental Pains is the thorough 
and complete removal of the cause, generally consisting of necrotic 
pulp tissue, and infectious matter in the pulp chambei\ This should 
be thoroughly removed by mechanical means, assisted by the use of 
chemicals, and the entire chamber from crown to apex rendered 
aseptic as soon as possible. 

If Pus Has Formed at the apical space and flows freely down the 
root canal temporary relief is most certain to follow if the case is 
allowed to remain open for twenty-four or forty-eight hours for 
free drainage, when further treatment may be proceeded with. 

Acute Alveolar Abscesses should be opened externally, as soon 
as the presence of pus can be diagnosed, this to be done external to 
the alveolar wall and is least painfully done by freezing the tissues 
to be punctured. 

Abscesses Are Assisted to the Surface by painting the mucous 
membrane over the diseased portion with aconite and iodine. In no 
case should such an abscess, no matter what its size, be lanced through 
the external surface of the face as all are easily reached from within 
the mouth. 



CHAPTER XXXI. 
PROPHYLACTIC TREATMENT OF THE MOUTH. 

The Importance of Prophylactic Treatment early in a series of 
visits to a dentist and at stated periods thereafter, is second only 
to the relief of pain, the neglect of which jeopardizes the remain- 
ing tooth structures, the permanency of attempts to check the 
ravages of caries and disease, as well as the reputation of the op- 
erator's skill. 

Unhygienic Conditions About the Teeth are the sole, immediate 
and exciting cause of primary or secondary decay of the teeth, 
and many an* operator of exceptional skill as to the making of 
fillings has failed from a disregard of these conditions. As much 
of the success of dental operations depends upon the care of the 
mouth by both dentist and patient in the way of prophylaxis, as 
upon the skill of the dentist as an operator. The making of a fill- 
ing is but the repair of an injury and is only a temporary check 
to the progress of destruction, if the primary cause of dissolution 
is to remain operative. 

The Sub-Dental Tissues are also diseased by a lack of prophy- 
laxis to the extent, luany times, of their entire loss, so that the 
teeth, themselves, are loosened and lost, through a lack of struc- 
tures to support them, Avhile the teeth so lost are many times yet 
undecayed, and, in the present-day advancement of dentistry, ex- 
perienced operatoi's are forced to consign more teeth to the for- 
ceps from the result of diseased conditions in the tissues surround- 
ing them than from decay of the teeth, themselves. If this be 
true the dentist cannot ignore the importance of combating the 
agencies Avhich l)ring it about. 

Preventive Dentistry has tlie same great field of usefulness as 
bas ''preventive medicine" in the practice of medicine and the 
dentist who masters this phase of the science of dentistry has gone 
a long way towards success, and many defects in manipulation, 
ability and ideals in conditions about tooth repair impossible of at- 
tainment, will stand the test of time if only hygienic conditions 
are attained and maintained. 

The Kinds of Deposits Upon the Teeth are generally classified 
as salivary calculus, serumal calculus, green stain and sordes. 

The first two named are enemies to tissue about the teeth, while 

ISO 



PROPHYLACTIC TREATMENT OF THE MOUTH 181 

the last two are responsible for most of the destruction of the 
hard dental tissues by caries. 

Composition of Salivary Calculus. Mixed saliva contains in 
man an average of about 0.5 per cent solids. The calculus is pre- 
cipitated into the mouth in a form of a finely divided calco- 
globulin, which collects in masses upon any stationary object, 
close to the mouth of the gland ducts. The fresh deposit is very 
soft and greasy to feel when first deposited, but Avithin twenty- 
four hours it begins to harden and increases in hardness up to the 
time of thirty or sixty days, when it has generally attained its full 
hardness and Avill break away from the stationary object in masses 
showing distinct lines of fracture. 

Lime Salts Held in Solution. Calcium phosphate and magnesium 
phosphate are held in solution in the saliva, made possible by the 
presence of a little carbon dioxide. 

Reasons for Precipitation. When the saliva is discharged into 
the mouth it is released from the normal blood pressure and some 
cf the carbon dioxide escapes which allows the calcium salts to be 
precipitated. The lactic acid which is continually formed in the 
mouth converts the mucus into a curd in which the calcium salts 
are entangled to harden into salivary calculus. This process is as- 
sisted by the presence of the oxygen taken into the mouth with the 
breath, which facilitates the liberation of the carbon dioxide, in 
the process of oxidization. 

Time of Deposits. It would seem from the experiments of Dr. 
Black that the deposits of salivary calculus are paroxysmal and 
also that these periods of rapid deposit follow the ingestion of 
heavy meals. He thinks that these periods of excessive deposits 
come at a time Avhen the blood is overcharged with food pabulum. 

Kind of Food. It does not seem from his experiments that the 
kind of food has very much to do with these deposits. The more 
easily a food is digested, the more quickly following the meal will 
these deposits appear. 

Habits of Patient. It would seem that the habits of the patient 
have little to do in influencing the amount of these deposits. 
However those Avho live a life of physical exertion, which favors 
the using of heavy meals have a greater tendency to deposits of 
tartar than those whose vocation would cause them to eat lightly. 

Mouths Most Subject to the Deposit. From our present under- 
standing of this subject it would seem that the mouths most sub- 
ject to the deposit of salivary calculus are those individuals, 



182 OPERATIVE DENTISTRY 

First, who from constitutional reasons have a tendency to an 
abundance of carbon dioxide in the excretions and secretions. 
This condition may be brought about by great physical or mental 
activity or w^here the skin, kidneys or lungs, or all, are not per- 
forming their full functions. These are the principal eliminaters 
of carbon dioxide. Such individuals are very liable to be troubled 
with precipitation within the gland and ducts, through which their 
secretions are expelled, resulting in cystic, glandular, biliary or 
renal calculi. 

Second, those individuals who either occasionally or habitually 
engorge heavy meals, wherein the quantity of such meals is greater 
than that needed for growth or maintenance. 

Third, in mouths wherein the ajuount of lactic acid is more than 
normal. 

Fourtli, in the mouths of public speakers and mouth breathers, 
whether awake or during sleep. The great amount of oxygen com- 
ing in contact with the saliva assists in the rapid liberation of the 
carbon dioxide and consequent rapid precipitation of the calcium 
salts. 

Prevention of Salivary Deposits. It Avould seem that salivary 
deposits can largely be prevented by stimulating the circulation; 
stimulating the elimination of carbon dioxide from the body; 
checking mouth breathing as much as possible, correcting over- 
acidity of the mouth, limiting the amount of food taken into the 
stomach at each meal by more nearly equalizing the three daily 
meals to the needs of the body. Also by so highly polishing the 
surfaces of the teeth upon which the deposit is precipitated, as to 
facilitate the mechanical removal of the fresh deposits. Last but 
not least, so instructing the patients in the mechanical features of 
the care of their teeth that insofar as possible all fresh deposits 
are removed before hardening takes place. 

Serumal Calculus is a calcic precipitate from the 1)lood. The 
salts in solution in the blood as well as the stability of suspension 
depends materially upon the presence of a normal amount of car- 
bon dioxide. 

Serumal Calculus Is Deposited beneath the gum tissue wherein 
there is a passive hyperemic condition oi- congestion. Here we 
have excessive tissue waste, lessened alkalinity of the blood, a lib- 
eration of the carbon dioxide and consequent precipitation of the 
inorganic salts. By the recession of the gum after the formation 



PROPHYLACTIC TREATMENT OF THE MOUTH 183 

of the seriimal form of calculus, it may be exposed to view, or 
mixed with the mass of salivary calculus. 

Senimal Calculus in Appearance is of a much darker color than 
salivary of a harder constituency, and generally adheres to the 
surface of the tooth more tenaciously. 

Serumal Calculus Is Also Found on unexposed portions of roots 
of teeth which approximate inflammatory exudates, or, are bathed 
in escaping blood plasma associated with chronic conditions of the 
apical space. It also appears in other portions of the body as 
about the joints subjected to chronic inflammations as well as in 
the glands continually gorged with blood. 

The Bulk of Serumal Calculus is comparatively small, owing to 
its formation in restricted spaces and is generally found in small 
nodules, narrow bands and thin scales, not always easy of detec- 
tion or removal. 

Stains Upon the Teeth are of varying degrees of shade in several 
colors and from cosmetic reasons stand for immediate removal 
when detected. However the green stain found upon teeth is so 
closely connected with the first stages of caries on surfaces so af- 
fected that it deserves special consideration. 

Green Stain Is Generally Confined to the labial surfaces and 
particularly the gingival third of the anterior teeth. It is most 
frequently found upon the teeth of children and may be seen 
either upon the temporary or permanent teeth. When it persists 
for a considerable time upon these surfaces of the permanent 
teeth the enamel will be found to be etched by a dissolution of the 
cemental substance evidenced by the whitened surface. 

The Color Is Due to the bacteria present. 

The Injury to Tooth Substance is due to the acid which these 
bacteria produce. 

The Reason for Their Presence is the favorable place for lodg- 
Dient afforded by the persistence of the cuticula dentis. 

Sordes Consists of a mixture of food, epithelial matter and 
micro-organisms collected upon the teeth. 

Neglect in the Removal of Sordes results in tooth caries, partic- 
ularly in localities habitually so unclean. 

The Removal of Salivary Calculus is accomplished by two prin- 
cipal plans, the push-cut method and the draw-cut method, each 
with its advantages. 

By the Push-Cut Method the blade of the scaler, which has a 
blunt chisel edge, is forced between the calculus and enamel trav- 



184 OPERATIVE DENTISTRY 

eling in the direction of the root. In its use the principal danger 
is the slipping of the instrument to the gum tissue beyond and this 
accident should be well guarded against by first securing a pos- 
itive and sufficient hand rest. 

By the Pull-Cut Method the blade of the scaler, which has a hoe 
point of about twenty-eight degrees, is first passed under the free 
margin of the gum, its point engaged on the ledge of the calculus 
and its removal accomplished by a pulling force applied toward 
the crown of the tooth, or in a plane parallel v\dth the long axis of 
the tooth. Care should be taken in passing the instrument under 
the free margin not to lacerate the gums. Pen grasp should be 
used and a secure hand rest obtained before making an effort to 
remove the deposit. 

The First Teeth to Be Scaled is not important, yet if attention 
is first directed to the lingual surfaces of the lower incisors, we 
are able to create an impression upon our patients of the impor- 
tance of the work in hand. It is here we generally find the heavi- 
est deposits and by removing these first, and allowing them to 
fall in the mouth the patient is fully aAvakened to the need of the 
service being rendered. The same impressions never seem possible 
if the removal of the larger masses is left until the last. 

The Proximal Surfaces Are Best Scaled with the prmiing hook, 
draw-cut scaler or the straight push-cut having a very thin blade 
and about a tAventy-three degree bevel. 

These proximal surfaces will need such attention more from the 
deposit of serumal calculus than from the salivary variety, which 
is only present in the proximal surfaces after gum recession. 

The Removal of Serumal Calculus is much more difficult than 
salivary, as all of the work is done under the cover of the gum. 
which requires delicacy of touch and the highest degree of digital 
skill. 

Calculus Must Be DistingTiished From Cementum, bone and soft 
tissues, simply by the sensation of touch conveyed through contact 
of the instrument with the structures in question. 

The Surface of Roots, where the attachment of the perice- 
mentum has been lost, must be carefully examined and the re- 
moval of all calculus accomplished, and the root or roots thor- 
oughly polished, as the gum will not regain health where particles 
of the deposit remain. Several sittings are often necessary to ac- 
complish satisfactory results. 

Pyorrhea Alveolaris. The desire to keep this book within cer- 



PROPHYLACTIC TREATMENT OF THE MOUTH 185 

tain limitations prevents the consideration of pyorrhea in its treat- 
ment. However the foregoing procedure will go far towards the 
prevention and cure of pyorrhea alveolaris. In fact thorough 
prophylaxis is the prime essential in the treatment of that disease. 

The Removal of Green Stain is principally accomplished by the 
application of some abradent, as pumice stone, with a revolving 
brush in the dental engine. This also polishes the crow^ns of the 
teeth, removing the small particles of calculus still adhering to 
them after scaling. 

Hydrogen dioxide (H0O2) added to the powdered pumice in 
place of water will assist in removing the stains and particularly 
green stain, of which it is a partial solvent. Following the use of 
pumice the gums should be thoroughly syringed with water to re- 
move any trace of the pumice, which is insoluble in the mouth and 
should not be left around the free margins of the gums. 

A Clean New Brush Wheel should be used and a fresh mix of 
the powder made for each patient as a means of preventing the 
transmission of disease as well as from a standpoint of cleanliness. 
As well might our patients be asked to all use the same toothbrush^ 
a thing not thought of, even by members of the same family. 

The Removal of Sordes is a matter which must be left to the ef- 
forts of the patients. Its accumulation about favorable portions 
of the teeth and mouth is but the matter of a night or a day and 
upon its speedy and frequent removal depends the salvage of the 
teeth from the ravages of caries. 

The Toothbrush is the one great cleansing agent and nine-tenths 
of the removal of sordes is accomplished purely by mechanical ab- 
rasion through the movements of the bristles of the brush over the 
surface of the teeth. The movements of the bristles should be not 
only crosswise to the long axis of the teeth, but also from root to 
crown and vice versa, that the travel of the bristles may parallel 
the gingival, enter the embrasures and traverse the grooves and 
fissures. 

Hydrogen Dioxide Is the Only Agent which can be used in the 
mouth in sufficient strength to dissolve sordes and not injure 
either the hard or soft oral tissues. This may be used either upon 
the brush or as a mouth wash. The dissolution of sordes is accom- 
plished by oxidation. 

The Massage of the Gums is advised to remove all unsolidified 
calculus, food particles and other foreign substances from beneath 
the free margins of the gums as this appears to be the only satis- 



186 OPERATIVE DENTISTRY 

factory method of cleansing these spaces. The massage is also 
most beneficial to the gums. It stimulates the circulation, retards 
tissue waste and lessens the deposit of serumal calculus, and in ad- 
dition forces away that which has been precipitated before it has 
an opportunity to solidify. 

Instructions to Patients as to the care of their teeth is an all- 
important duty of the dentist, not only from the standpoint of 
what is best for the patient, but much of the dentist's reputation 
as an operator depends upon the subsequent care given the teeth 
by the owner following the making of fillings, for upon their en- 
vironment depends their permanency. Comparatively few indi- 
viduals know how to properly care for the mouth and many will 
insist to their dentist that they are most careful of their oral hab- 
its when upon examination, the dentist finds surfaces which appear 
never to have been cared for in the least. They have failed to 
reach these surfaces with their brush. 

The Technic of Proper Brushing should be thoroughly ex- 
plained, with special reference to reaching the surface which they 
seem to be neglecting. Instruct them as to the massage of the 
gums with the finger tips, rubbing not only crosswise but also 
from root to cro^^ai, assuring them that if the gums bleed easily it 
is all the more essential that they repeat the operation and that 
finally they will regain their normal health and then they will not 
bleed under the treatment advised. 

The Use of Floss Silk for passing through the proximal spaces 
to clean contacting surfaces by wiping off the embrasures and 
reaching points inaccessible to the brush, should be demonstrated 
to the patient. 

Care should be taken not to snap the thread past contact points 
as it may lacerate the gums. 

Toothpicks have no place in the care of the teeth and should be 
prohibited by law, especially those of soft wood so commonly 
found on the market and at public eating houses. Their square 
corners and slivered ends irritate the gums, causing their disease 
and recession thereby destroying the natural protection to the 
most vulnerable portions of the teeth. 



CHAPTER XXXII. 
EXCLUSION OF MOISTURE 

The Exclusion of Moisture from most operations upon the teeth 
is essential to the successful manipulation of most filling materials, 
the sterilization of tooth structures and the prevention of infec- 
tion, the cleanliness of cavity walls and margins, that a perfect 
view of the cavity may be obtained, that the extent of decalcifica- 
tion may be observed, to diminish the pain of operations on living 
dentine and to protect the soft tissues from injury in the use of 
caustic drugs, as well as to save time of both patient and operator. 

The Methods of Securing Dryness during operations are here 
given. 

The Rubber Dam, invented and given to the dental profession in 
1864 by Dr. Sanford C. Barnum, of New York City, is widely used. 

Absorbents, as napkins, cotton rolls and pads packed about the 
teeth and near the ' mouths of ducts, assisted by specially con- 
structed clamps upon the teeth are also used. Dryness is also se- 
cured by the use of tlie saliva ejector whereby the mouth is con- 
tinually drained of the secretions. 

The Objections to the Use of the Rubber Dam are entirely on 
the part of the patient and can generally be traced to awkward 
and unskilled handling on the part of the operator. Every oper- 
ator should become dextrous with each method, that he may em- 
ploy the one most expedient in every case, using the one least 
objectionable to the patient. 

The Neglect of Dryness in dental operations is to invite disaster 
in root canal treatment, as well as short life to all fillings so placed, 
and the operator who makes it a practice to neglect this essential, 
obtains only a partial success in that which he attempts. 

So Important Is Dryness that a patient should be warned that 
a certain operation, where moisture has been allowed to flood the 
field, is short-lived at best and is liable to failure from this cause. 
Such conditions seldom arise but are occasionally met with, due 
to location and extent of decay and also from the fact that there 
are some patients who are nauseated by the presence of the dam 
or absorbents about all but the most anterior teeth. 

All Filling Materials are better manipulated under dry condi- 
tions at some stage of the operation, porcelain being the only one 
demanding moist conditions at any stage of the process. This 

187 



188 OPERATIVE DENTISTRY 

moisture in porcelain filling is only required to preserve the shade 
of the tooth substance to be imitated in the fused filling. 

Those to Which Dryness Is Most Essential are silicate, cohesive 
gold, cement amalgam and gutta-percha, named in the order of the 
importance of the demands. It is true that all of these excepting 
silicate may be successfully manipulated under moist conditions, 
but the effort is greater and the certainty of success is materially 
decreased. 

The Exclusion of Moisture for Sterilization and the prevention 
of infection is imperative in the last stages of cavity preparation, 
as it is physically impossible to properly perform the toilet of the 
cavity and properly sterilize the same when flooded or even under 
moist conditions. 

The Proper Treatment of Pulp Canals cannot be accomplished 
vi^hen flooded by the oral fluids to say nothing of the introduction 
of a permanent root filling. The saliva is at all times impregnated 
with various forms of bacteria. Its presence invites failure by pre- 
venting sterilization of canals already septic and permitting the 
re-infection of those already sterile. 

Cavity Walls, and particularly the beveled margins, must be 
freshly cut and planed after being moistened before the introduc- 
tion of a filling, as this is the only means of having an absolutely 
clean surface. We may resort to absorbing and evaporating the 
moisture from the walls and margins of a cavity, but there will 
invariabty be left a residue or film upon the surface which is solu- 
ble in the oral fluids. No amount of pressure in introducing the 
filling, be it rubber, amalgam or cohesive gold, will displace the 
moisture absorbed by the cavity surfaces, hence we have this layer 
cf moisture or sediment intervening the filling and cavity. This 
will be exchanged in course of time for that upon the outside 
carrying with it bacteria and the products of fermentation or lac- 
tic acid and secondary caries is the result. Bacteria, which are the 
active agents of caries, will go where moisture will not, and the 
lactic acid which they secrete will go where the space is too small 
for the bacteria. It will therefore be readily seen that a moist sur- 
face or one coated with a residue of an evaporated mixture, 
whether medicine or saliva, intervening between a filling and a 
cavity wall, becomes a large passage way for the greatest enemy 
to tooth substance — lactic acid. 

A Better View of the Cavity Is Obtained When Dry, as its out- 
lines become more distinct and its size and shape better defined. 



EXCLUSION OF MOISTURE 189 

No mechanic ever thinks of trying to accomplish his best work 
with the object submerged in moisture. The rays of light are 
broken, objects are distorted and distances misjudged. The dentist 
who does not effectually exclude the moisture from the immediate 
neighborhood of a cavity will catch only a glimpse now and then 
of portions of a cavity, this being particularly true of the gingival 
Avail, except in cases of gum recession. 

The Extent of Decalcification of both dentine and enamel is di- 
agnosed only when dryness is obtained to bring out the colors and 
shades of each incident to these conditions. It is impossible to 
make proper cavity extension until the cavity has been made dry 
and so maintained for some time, as this is often the only means of 
detecting superficial caries. Semi-decalcified tooth substance, when 
moist, materially resembles the healthy structures and must be 
dried to detect its injured condition. 

The Pain of Cavity Excavation is materially decreased by the 
extraction of the moisture from the dentine. The protoplasm 
within the dental tubules is the means of transmitting the sensa- 
tion of pain to the vital pulp. Water is a large constituent of pro- 
toplasm and the extraction of this moisture through extreme and 
continued dryness removes the media of sensitiveness. It is there- 
fore but humane that the cutting of dentine be done with the mois- 
ture excluded. 

When Using Caustic and Concentrated Drugs the moisture 
should be excluded, that the drug may not be carried away to the 
injury of adjacent tissues and that the drugs may not be diluted 
to detract from their efficiency in accomplishing that for which they 
were used. Drugs placed in the cavities of teeth with moist mar- 
gins even when placed under fillings of rubber, cement or amalgam, 
will follow the moisture of these margins to join that without and 
great damage to the surrounding tissues often results from no other 
cause than a lack of the exclusion of moisture during the operation. 

As a Time Saver the exclusion of moisture should not be over- 
looked. "With a dry cavity the continued uninterrupted view per- 
mits of more continuous work by the dentist. He does not have to 
wait for the patient to expectorate, make a few remarks and leisurely 
resume his position in the chair, not always in the position desired 
for operating. The operator will also be saved much time in dry- 
ing the cavity after each flooding. All this takes valuable time, much 
more than is required to adjust a dam. 

The Rubber Dam is the most dependable means of securing a dry 



190 OPERATIVE DENTISTRY 

field for operating and its proper and speedy adjustment should be 
mastered. It is made in three thicknesses ; heavy, light and medium, 
the medium being the weight best adapted for all purposes where 
only one weight is to be kept at hand. 

The Size and Shape is of little importance so long as it com- 
pletely covers the mouth after it has been made to isolate the teeth 
desired, as well as cover the chin and extend to either side of the 
mouth sufficient for the proper engagement of the holder. This will 
require a piece from five to six inches square, for all cases back of 
the six anterior teeth and is most frequently the size used on the 
anterior teeth. However, some economy of rubber dam may be prac- 
ticed by cutting these squares in two triangular pieces, each of which 
will do for a separate case. These are applied with the diagonal of 
the quadrilateral (hypotenuse) uppermost. 

The Holes to Receive the Teeth should be of the proper size and 
smoothly cut, otherwise there is an increased liability of being torn 
in adjustment. This is best done by the use of the rubber dam 
punch to be had at dental depots. However, in the absence of this, 
a very good result is obtained by drawing the rubber tightly over a 
tapering round handle of an instrument and touching the sharp edge 
of a knife to the rubber down the side of the handle when a per- 
fectly round piece will be cut out. 

The Distance Between the Holes will vary according to the space 
between the teeth, the height of the festoon of the gum, the weight 
of the dam and the size of the teeth to be engaged. Generally speak- 
ing, the holes are cut from two to four millimeters apart in medium 
dam. The lighter the dam the farther apart should be the holes. 
The holes are farther spaced with extremely large gum festoons, also 
when there is a considerable gum recession. If the holes are too close 
together in above condition the dam may not cover the entire proxi- 
mal tissues and a leakage may occur, or the gum septa may be un- 
duly compressed and permanent injury result from strangulation. 
If the holes are too far apart the rubber will wrinkle and bag at the 
proximal spaces and seriously hinder operations in these localities. 

The Location of the Holes in the piece of rubber dam depends 
upon the location of the tooth to be operated upon and the teeth 
to be isolated. A beginner will do well to first place the dam over 
the mouth in the position desired for the outside edges, request the 
patient to open the mouth and with the finger cause the dam to come 
in contact with the occlusal surfaces of the teeth it is intended to 
include and then punch the holes as this trial indicates. Bv this 



EXCLUSION OF MOISTURE 191 

method the operator will soon become familiar with the location in 
each case. 

The Number of Teeth Isolated depends upon the location and the 
operation to be performed. For the short treatment cases, sometimes 
the placing of one or two teeth under the dam will suffice, but in 
most cases where fillings are to be made and polished, from five to 
eight teeth should be included that a good view of the field of opera- 
tion may be had and the loose folds of dam carried farther away to 
avoid them catching in the revolving points of the engine. 

With Anterior Teeth the first bicuspid tooth of either side should 
be included, as the cuspid from its conical shape is many times 
unsafe for a final ligature. 

With Bicuspids and Molars as the objective teeth in an opera- 
tion, there should also be included the teeth anterior to the median 
line. 

The Clamp should be placed on the tooth back of the one to be 
operated upon, excepting in mesial cavities in second molars when 
the clamp may be placed on the second molar, thereby avoiding the 
clamping of the third molar except when absolutely necessary, as 
with distal cavities in second molars. 

The Placing of the Dam requires the freedom of both hands of 
the operator, and the aid of an assistant is of value. The necks of 
the teeth upon which the rubber dam is to be placed should be cleansed 
of all calculus and sordes and flooded with a jet of water from the 
syringe. If the gums show hypersensitiveness they should be bathed 
in a solution of novocain, restricting its use to the gingival borders. 
Waxed silk should be passed through the proximal spaces to clean 
them and prove access for the rubber. If sharp margins of cavities 
cut the silk these should be dulled by passing a thin ribbon saw 
through the proximal space or, with the chisel, carry the margin 
sufficiently into the embrasure to give access. 

When teeth are in close contact so that the silk thread is passed 
with difficulty, the rubber can be made to pass more readily by the 
use of soap, which is done by placing the row of holes on the ball 
of the index finger, occlusal side up, and rubbing the soaped fingers 
of the other hand across the holes. 

The Occlusal Side of the Rubber Dam is that side which is to- 
w^ard the occlusal surface when the dam is in position. 

The Gingival Side is the opposite side and is next to the gingival 
margins when the dam has been applied to the teeth. 

The Method of Applying the Dam is affected by the fact of 



192 OPERATIVE DENTISTRY 

whether a clamp is used or not and kind of clamp when one is used. 

With the Anterior Teeth we do not generally use a clamp and the 
rubber is placed by commencing at one side and then crowding the 
rubber through each proximal space in the order they should go, 
until the opposite side is reached. The rubber dam holder should 
be applied to one side before commencing the adjustment, and, as 
soon as the teeth have been forced through the holes, the other side 
of the holder should be attached. 

With Posterior Teeth the holder should be attached to the short 
side of the rubber to prevent curling into the mouth, which would 
be the same side of the dam as the teeth are situated in the mouth, 
right or left. Adjust clamp to be used as this tooth receives first 
attention, while the remaining teeth are one by one pushed through, 
until the most anterior one is reached, when the remaiiiing side of 
the rubber is secured with the holder. 

To Prevent Leakage Around the Teeth the edges of the holes 
must turn toward the roots. This is accomplished by first pressing 
the dam w^ell against the gums while grasping the rubber on either 
side of the tooth and drawing it tight, then releasing the rubber so 
that it slackens and then gently moving it occlusally. This will gen- 
erally have the effect of inverting the edges. If inversion is not 
complete pass a small blunt instrument, as a spatula or dull ex- 
plorer, around the gingival to turn the edge under. 

The Use of the Ligature is to assist in inverting the edges of the 
holes in the rubber dam and to secure the edges about the teeth in 
this position against displacement by the movements on the part of 
the patient or the operator. 

Caution in the Use of Ligatures is most important as much per- 
manent injury is done the gingival attachments by the careless crowd- 
ing of these on the dental ligaments. This is particularly the case 
where the proximal gum festoons are high as in these cases, espe- 
cially with young people, the attachment to the tooth is also high. 
A tight ligature tends to encircle the tooth in a straight line and 
would thereby ride down the high proximal attachments, if the lig- 
ature is crowded to the full height both labially and lingually. Hence 
either the labial or the lingual should not be crowded to the full height 
of the crown. 

Ligatures Are Made of well-waxed floss specially prepared for 
the purpose, cut into lengths of about five or six inches. Some econ- 
omy may be practiced where three teeth are to receive ligatures by 
starting with a piece about tT^'elve inches long. Tie the first tooth 
in the center of the strand and when the ends are cut off enough re- 



EXCLUSION OF MOISTURE 193 

mains for the other two, thus getting three out of the amount usually 
used for two. 

The Cutting of the Loose Ends may be practiced for all the teeth 
except the lower anterior, cutting two or three millimeters from the 
knot. With the lower anterior teeth, ends of two or three inches 
should be left from each knot and the farther ends of all tied to- 
gether, and weighted to overcome the efforts of the patient to ele- 
vate the lower lip, which endangers the security of the dam. 

The Most Popular Knot for tying ligatures is the ''surgeon's 
knot," either full or half. This knot is made by passing the ends 
around each other twice before each tie is made, for the ''full sur- 
geon's knot," while for the "half surgeon's knot" this is done with 
only the first half of the knot. 

The " Wedelstaedt Tie" is even more secure than the above and 
is made by using the first half of a "surgeon's knot" on the lingual 
iside of the tooth first and then passing contacts with the ends on 
either side of the tooth, complete the operation with a "half sur- 
geon's knot" on the labial, thus circling the tooth with two strands. 

The Removal of Ligatures from the tooth when the operation has 
been completed should be accomplished before the rubber dam has 
been disturbed, and is best done by the use of a small sharp-pointed 
knife as a No. 1 gum lancet. The thread should be severed to one 
side of the knot on the labial or buccal side, and by grasping the knot 
with a pair of pliers, the thread is pulled through from that side. 

Where Amalgam Fillings Have Just Been Completed in a prox- 
imal space the ligature about a tooth so filled as well as that around 
the proximating tooth should be cut so that the part lying gingivally 
from the fresh amalgam will be loosened and will pass out to the lin- 
gual embrasure. The ligature about a tooth in which there has just 
been completed a filling in both the mesial and distal should be cut 
on the lingual portion. This action will result in both ends being 
loose ends. Attention to this point will prevent the ligature plowing 
a ditch in the amalgam and destroying the filling, in many cases, at 
the gingival-cavo-surface. 

A Good Rule to Remember with mesial fillings is to cut to the 
mesial of the knot; with distal fillings cut to the distal of the knot 
and where a tooth has both mesial and distal fillings cut ligature on 
the lingual. 

The Selection of the Clamp should be made and then tried on 
the tooth it is intended to be used upon. One should be secured 
that has jaws which fit the contour of the tooth at its gingival bor- 
der, that will remain in position and yet does not hug the tooth so 



194 OPERATIVE DENTISTRY 

tightly as to cause the patient pain or in any way injure the soft 
tissues. 

The Method of Applying the Clamp with the dam is to stretch 
the rubber over the clamp, then apply the clamp forceps and carry 
all to position on the desired tooth, using the hole in the dam thus 
intended as a means of getting a view of the tooth to be clamped, 
which aids in the placing. 

Some of the older makes of clamps require that they first be placed 
in position on the tooth and then with the first fingers of each hand 
the hole is distended in the rubber dam sufficiently to permit it to 
slip over the bow of the clamp. 

In Using Cervical Clamps for cavities on the buccal and labial 
surfaces in the gingival third the dam is first passed to position and 
then the clamp applied. 

The Removal of the Rubber Dam is accomplished by the follow- 
ing order of procedure : 

First — The removal of the ligations as before described. 

Second — Pull the rubber to the buccal or labial and with a sharp 
pair of scissors cut strips passing between the teeth. 

Third — Disengage one side of the dam holder. 

Fourth — With the right hand remove the clamp which should 
be holding the rubber dam, remove all clear of the mouth immedi- 
ately, as the patient does not take kindly to any delays at this 
stage of the procedure. 

Fifth — Inspect the rubber to see if it has all been removed. 

Sixth — Inspect the teeth for any portions of rubber dam, liga- 
tures or stray particles of filling material. Now proceed to knead 
the gums with the fingers, at the same time flooding them with 
a forceful stream of water from the syringe, to cleanse them and 
to re-establish circulation. 

The Use of Absorbents may be resorted to in place of the rubber 
dam for short operations and more particularly with the upper 
teeth as these are the most easily managed. Absorbents are to 
be had in the market in the form of rolls and napkins at small cost 
and are to be discarded after once used, which is the only hygienic 
method. In their use particular attention must be paid to the 
mouths of the ducts responsible for the most abundant secretions 
and the absorbents so placed as to not only readily absorb the fluid 
which is ejected, but also that they compress the ducts thereby re- 
stricting the flow. 



CHAPTEE XXXIII. 
TREATMENT OF HYPERSENSITIVE DENTINE. 

Hypersensitive Dentine is dentine which is more than normally 
responsive to mechanical or chemical irritation. 

Normal Healthy Dentine is only slightly sensitive, but when ex- 
posed to abnormal conditions and irritating agents it may become 
excruciatingly hypersensitive. 

The Sensations Are Conveyed to the Pulp by means of the con- 
tents of the dental tubules which are prolongations of the odonto- 
blasts. The odontoblasts are thickly surrounded by the terminal 
fibers of the nerves within the pulp. 

The Contents of the Tubuli is largely protoplasm and although 
this has the power of transmitting sensation in response to irrita- 
tion, it has not yet been demonstrated that the nerve fibers enter 
the tubuli or penetrate their contents. Hence it cannot be said 
that there is nerve tissue within the dentine. 

The Direct Cause of Sensitive Dentine is the loss of the enamel 
which is the natural covering of the dentine. 

The Most Common Agent in the removal of tliis normal covering 
is caries, which exposes the dentine to mechanical injury through 
contact with foreign substances and chemical irritants, particularly 
the acids of fermentation. 

Rapidity of Caries has much to do with the degree of hyper- 
sensitiveness in dentine, as shown in the white and light stages 
or rapid forms of caries wherein the sensitiveness is most exalted, 
while with the dark, yellow and brown varieties it is not so marked 
and with the black or slow progressing form of caries the sensitive- 
ness is scarcely above normal. 

The Most Sensitive Part of a Carious Tooth is at the junction of 
the dentine with the enamel or cementum at the periphery of the 
tubuli. It is therefore evident that the second stage of caries will 
show a higher degree of hypersensitive dentine *than the deep-seated 
stages and that the preliminary steps in cavity preparation in this 
division of caries Avill be more painful than the deeper cuts into the 
dentine, as then the more sensitive part has been passed. 

Mechanical Abrasion is also an agent which produces hyper- 
sensitive dentine by first wearing away the enamel and then en- 
croaching on the dentine. However, this process may be so slow 
and the irritation so slight as to act as a stimulus to the odontoblasts 

195 



196 OPERATIVE DENTISTRY 

and result in the obliteration of the dental tubuli by the deposit of 
calcific matter termed '' tubular calcification." When this is the 
result all sensation may be absent. 

Exposure of Cementum through gum recession is another excit- 
ing cause of hypersensitive dentine aggravated by allowing the ac- 
cumulation of sordes about the exposed cementum. 

Abnormal Oral Secretions often produce hypersensitive dentine 
and may be particularly looked for in the convalescent stages of 
fevers, as well as in dyspepsia, neuralgia, pregnancy, pulmonary tu- 
berculosis and acute rheumatism. 

Hypersensitive Dentine is found in poorly calcified dentine in- 
cluding the teeth of the growing child; teeth that have not been 
erupted for more than a few months; the teeth of those who follow 
indoor lives, particularly if they are under a heavy mental strain, 
as well as anything which may produce nervous irritation or debility. 

The Varying Temperaments of Patients must be studied and un- 
derstood to best cope with the problem of hypersensitive dentine. 
The suffering is actual upon the part of some, while there are those 
who magnify every pain and seem to be able to stand nothing and 
make as much fuss about a pin stick as it would be possible for them 
to make were they thrust through with a bayonet. The operator must 
separate these classes and vary the methods. He must understand 
the actual conditions and, by kind words of encouragement and a 
positive procedure, stimulate the nervous to withstand the necessary 
pain. This can only be done when the operator has full control of 
his own feelings, seeing to it that his temper is not ruffled, for, hav- 
ing lost control of himself, he has no control over the patient. 

Highly- Wrought, Nervous Temperament is, by nature, sensitive 
to impressions, especially augmented by environment or occupation 
and calls for the most skillful management of both patient and teeth. 
People of this type are generally of a high order of intelligence and 
when handled hy a master hand prove a most desirable clientage. 

Patients of This Temperament will permit being hurt for a short 
time provided something definite has been accomplished. They should 
be advised at times as to the coming pain, and for what purpose it 
must be inflicted, as the forming of an angle or the flattening of a 
wall, explaining, when done, that that which had been intended has 
been accomplished. They will stand for no awkwardness or fumbling 
but admire exactness and precision and are the class which will re- 
ward the dentist most liberally for painstaking efforts and actual 
achievements. This class make the day long but they serve to stim- 



TREATMENT OF HYPERSENSITIVE DENTINE 197 

ulate the dentist to his best efforts and work to the advancement of 
the really progressive operator. 

The Irresponsible Individuals Avho have no mental or physical 
stamina require a strong hand to control them in any emergency in 
life. They go to the dentist only when forced there by pain or are 
children brought by their parents. While a dentist should never be 
harsh with any patient, yet this class will necessitate, many times, 
stern commands, and a ''why, of course" method. In cases of this 
character where the operator has chosen to assume the role of a dis- 
ciplinarian, the stern proceeding should universally be tempered with 
the kindest of tones before the patient leaves the chair, that he may 
depart wdth the impression that the dentist is kind of heart and has 
been severe only for the patient's good. 

The Naturally Cowardly Patient who is strong, healthy and ro- 
bust, yet lives in mortal dread of any physical discomfort, is the hard- 
est class to manage. This class of patients have generally been raised 
in luxury and taught by example made possible by their environ- 
ment, that they should not even be inconvenienced. They seldom 
work and mistake that tired feeling for sickness. To be hungry, cold 
or warm, is described by them as "simply terrible." With such, 
often the best an operator can do is simply to temporize to keep the 
teeth comfortable. To attempt thorough work merely drives them 
away to seek gas for painless extraction. 

The Patient Who Simulates Pain should be early detected and 
severely dealt with. An operator should remember that a large 
amount of the gesticulation, grabbing the working hand, cringing 
and outcry, is simply voluntary on the part of many patients to in- 
form the dentist that he is hurting them. Most of this can be done 
away with by the following procedure: 

First tell the patient that "this will not hurt you," and then pro- 
ceed to make the statement true by working on enamel margins, 
even to gently scratching on the external surface. Then state to 
the patient that "this may hurt a little" and the operator can pro- 
ceed to test the dentine for its sensitive portions. He may then pro- 
ceed to do the less painful parts of cavity preparation. Lastly when 
it comes to cutting the angles and cutting sensitive portions the pa- 
tient should be warned that this particular place may be sensitive 
but that a certain amount of cutting is necessary. Advise the pa- 
tient to hold still for just a second or two and then he will be allowed 
to rest. Caution him against moving during this brief period as 
it will undo what has been accomplished, necessitating his withstand- 
ing the pain again. Praise the patient for his bravery when he has 



198 OPERATI\^E DENTISTRY 

complied with the request and advise him as to the work accom- 
plished. All this instills confidence into the patient as to the den- 
tist knowing what he is about and as to his knowledge of the place 
and time that 'pain may be expected. Nothing unnerves a patient 
so much as to get the slightest idea that the dentist is not aware of 
the pain he is inflicting or that he has little care for one's sufferings 
and has no definite idea as to when it will end. 

The True Simulator of Pain will try to make the operator believe 
he is causing pain when he is not suffering at all, with the idea that 
the dentist will be frightened into extreme care in his case. This 
class is easily detected by scraping an instrument on a surface where 
pain is impossible, as the external surface of a tooth. If the demon- 
strations continue it is the operator's duty to inform the patient 
of the detection of the attempted deception and that such will not 
be further considered, at the same time advising him to save his 
demonstrations until he is hurt Avhen they will be considered, and 
every effort made to lessen the pain. 

The Agents for Relief of Sensitive Dentine are : 

First — Those which produce a physical change in the contents of 
the tubuli. as desiccation, heat and cold. 

Second — Those agents which destroy or disorganize the contents 
of the tubuli, as caustics and escharotics. 

TJiird — Those agents which, when applied, to the dentine, locally 
or hypodermically produce a condition of analgesia or absence of 
sensibility to pain, termed local anesthetics, and anodynes as phenol, 
menthol, morphine, oil of cloves, cocaine and novocain. 

Fourth — Those agents administered with the view of reaching the 
nerves of the pulp through the general system as bromide of potas- 
sium, nitrous-oxide chloroform, etc. 

Fiftli — The mechanical condition under which the cutting of sen- 
sitive dentine is done. 

Physical Agents. 

Desiccation Is a Physical Agent of great virtue in alleviating 
hypersensitive dentine and accomplishes the result by extracting the 
moisture from the tubuli, which is a large constituent of the proto- 
plasm. 

This Is Best Accomplished by first flooding the cavity with ab- 
solute alcohol which has an affinity for water, and then directing into 
the cavity a continuous stream of warm air which is more effective 
if the temperature can be controlled so as to gradually raise it to 
the highest point tolerable to the patient. Painless cavity excava- 



TREATMENT OF HYPERSENSITIVE DENTINE 199 

tion can be accomplished to the depth of desiccation which will vary 
with different cases. 

A Continuous Stream of cold air will have a similar action 
through its desiccating effect and is practiced where compressed air 
is at hand. The force with which the air is contacted with the cav- 
ity walls is a factor in its efficiency. 

Heat and Cold When Moist will produce physical changes in the 
protoplasm of the tubuli sufficient to destroy the sensation of pain. 

In any locality of the body a moderate rise in the temperature, 
particularly moist heat, quickens vital action and heightens func- 
tional activity. This is true of sensitive dentine and the tempera- 
ture must be materially raised before a stage of paralysis is reached. 

The Best Means of Applying This Method is to direct into the 
I)rotected cavity a forceful fine stream of water which can be grad- 
ually raised in temperature to the point of toleration, cutting the 
sensitive part of the cavity while the stream of water is still play- 
ing on the point being operated upon. 

With the Application of Cold to any part, vital phenomena of 
every nature is retarded and entirely ceases with the lower tem- 
peratures. 

The Best Method of Applying this principle is to spray the cavity 
with a highly volatile liquid as ethyl chloride, sulphuric ether, and 
its combinations with choloroform. The rapid evaporation lowers 
the temperatures, extracting the heat from that with which it comes 
in contact. 

The Primary Pain in Applying these agents may be lessened by 
filling the cavity, temporarily with stopping, directing the spray first 
on this and the surrounding parts and later removing the stopping, 
directing the spray into the cavity without causing much pain, pro- 
vided there is not a hyperemic pulp within the tooth, in which case 
all thermal changes must be avoided. 

The Electric Current (Cataphoresis) as a physical agent to ob- 
tund sensitive dentine should be mentioned. It has been used to as- 
sist in carrying various drugs into the dentine, to facilitate their ac- 
tivity, but its use has proved so unsatisfactory, in many ways, that 
further description of this method is unwarranted. 

Destroying Agents. 

Caution in the Use of Caustics and Escharotics to relieve sensi- 
tive dentine in deep-seated cavities will ijave much pulp complica- 
tions and great care must be exercised in their use not only for the 
safety of the pulp but also the soft tissues about the tooth must 



200 OPERATIVE DENTISTRY 

be effectually protected. Many caustics are not limited in their ac- 
tion and Avhen once applied on the dentine continue their destruc- 
tion to the envelopment of the pulp. Arsenic trioxide is a notable 
example of this. ' 

Zinc Chloride is one of the oldest and most efficient remedies for 
hypersensitive dentine. Its action is due to its affinity for water and 
its coagulating properties upon albumen. 

The Danger in its Use in deep-seated cavities is through the lib- 
eration of hydrochloric acid, which causes pain in case of a nearly 
exposed pulp. This effect may be modified by using it in a solution 
of one part chloroform and four parts alcohol. Add the zinc crystals 
to the proportion of five grains to the ounce. Clarify by adding a 
drop of hydrochloric acid. 

The Methods of Using Zinc Chloride are : 

First — Saturate a pellet of cotton with the above solution, place 
in the cavity and evaporate with a draft of warm air from the warm 
air syringe or chip blower. 

Second — Mix a thin paste of zinc oxychloride cement. Paint the 
sensitive dentine with this cement and cover with stopping or gutta- 
percha. After a few days or weeks, often, excavation may be ac- 
complished with little pain. 

Caustic Potassa and Carbolic Acid, equal parts (JRobinson's rem- 
edy), often relieves sensitiveness of the dentine and is. applied by 
placing a pledget of cotton in the cavity, always with the rubber 
dam in position to protect soft tissues. 

Silver Nitrate may be employed to good effect upon exposed 
surfaces of dentine in the posterior parts of the mouth, such as those 
on the occlusal surface of molars due to abrasions, or exposed ce- 
mentum. It reduces sensitiveness and by forming the albuminate 
of silver it retards decay even so far, in some cases, as to render 
the surfaces to which it has been applied immune to caries. On ac- 
count of its discoloring effect its use is not permissible in parts ex- 
posed to view. 

Formaldehyde. Formaldehyde is a protoplasmic poison and is a 
great desensitizer. The author called the attention of the profession 
to this method at the World's Columbian Dental Congress in 189f) 
in a paper before that convention. However, its irritating effects 
are sometimes injurious to the pulp and great care has to be exer- 
cised in its use, particularly that there is not a near pulp exposure. 
It is of advantage if the material can be so combined as to cause 
a slow liberation of the formaldehyde, which materially lessens dan- 
ger to the pulp and pain from its application. 



TREATMENT OF HYPERSENSITIVE DENTINE 201 

Local Anesthetics and Anodynes. 

Novocain stands first as a local anesthetic to desensitize dentine. 
The methods of using novocain for sensitive dentine are slov^ absorp- 
tion and injection by pressure, in the tooth and hypodermically. (See 
Chapter XLII.) 

The Slow Absorption Method is best practiced by puttnig into 
the cavity a one-sixth grain tablet of novocain; over this place a 
pledget of cotton which has been moistened v^ith the normal salt 
solution, and proceed to fill tooth with stopping, seeing the cavity 
again for excavation in twenty-four or forty-eight hours. 

Pressure Anesthesia of the dentine may be accomplished in two 
general ways. The dentine should be thoroughly sterilized, the above 
application of novocain in the normal salt solution made, over this 
a piece of unvulcanized rubber placed, and all crowded into the 
cavity with as much force as the patient will permit. 

High Pressure Syringes are sometimes of service to simply de- 
sensitize the dentine, but their use for this alone has never become 
general practice, due to the danger of pulp infection. 

Phenol (known to the laity as carbolic acid) is a valuable rem- 
edy for hypersensitive dentine, as well as for materially lessening 
the pain caused by the blast of air from the chip blower, and should 
never be forgotten when the patient complains of the air causing 
pain. In addition to coagulating the albumen in the tubuli it possesses 
analgesic properties. 

The Method of Using Phenol for sensitive dentine is to carefully 
desiccate the dentine with alcohol and warm air, applying a pledget 
of cotton saturated with the phenol, directing thereon a current of 
warm air until the cotton is nearly or quite dry. This should be 
repeated as often as the case demands. 

Oil of Cloves is a valuable remedy in this respect and the method 
of its use is the same as that just described for phenol. 

Oil of Cloves and Phenol Combined, as tAvo parts phenol and one 
part oil of cloves, applied to the dry open cavity and evaporated 
therefrom, with the current of warm air, is more effective than either 
the phenol or oil of cloves alone. This method with these agents 
has to recommend it the fact of being a good means of sterilization, 
it is a pulp pacifier in deep cavities, and no injury can reach the 
pulp, provided the temperature of the current of warm air is not too 
high. 



202 OPERATIVE DENTISTRY 

Through the General System. 

Potassium Bromide in 5-grain doses three times a day for forty- 
eight hours preyious to a sitting at the dentist's will do much to 
remove the nervousness caused by the fear of the intended visit and 
serve to minimize the pain to be endured. 

Nitrous Oxide when properly administered is of great value and 
efficiency. It should be combined with oxygen or compressed air in 
proper proportions. So combined and administered, it may be given 
for a protracted period, long enough to prepare one or more sensi- 
tive cavities without pain to the patient and in most cases with no 
danger to health or life. 

Somnoforme. Somnoforme when administered through a special 
apparatus is one of our most efficient means of rendering the patient 
semi-conscious and practically immune from any pain of dental opera- 
tions. In the administering of this as well as other anesthetics for 
analgesia, all of the rules pertaining to the administration of the 
same anesthetic for major operations must be observed as the same 
danger to life exists. 

Chloroform Slowly Administered and only to the first stage of 
anesthesia is a most valuable means of dealing with severe cases. 
This is particularly true of the A. C. E. mixture (alcohol, chloroform 
and ether, equal parts). The primary effect is to paralyze the sen- 
sory nerves, as the ends of the fingers, the skin and mucous mem- 
brane in general and this is true in the tooth's pulp with the fibers 
ending in the odontoblastic laj^er of cells wherein abundant sensitive- 
ness has been developed. 

The Method of Administration is quite the same as that for any 
other operation except that it is not carried past the first stage of 
anesthesia. All that part of the preparation of the cavity not pro- 
ducing pain is carried out, after which the dental chair is tipped 
back to as recumbent a position as will admit of operating. A nap- 
kin is then spread over the lower part of the face, leaving the eyes 
uncovered. The chloroform, or better the A. C. E. mixture, is added, 
first slowly a drop or two at a time and carried to the point where 
the patient feels a tingling sensation in the finger tips or expresses 
the fact that they begin to feel the effects of the drug. The anes- 
thetic should never be crowded or confined while the patient can 
smell the chloroform, but can be pushed more rapidly when the ol- 
factory nerves have been paralyzed, so that the sense of smell is lost, 
and it is not long thereafter until the dentine can be excavated pain- 
lessly. As soon as the operator begins to operate the assistant should 



TREATMENT OF HYPERSENSITIVE DENTINE 203 

hold to the nostrils a large-mouthed bottle of the anesthetic to pro- 
long the stage of anesthesia reached. At no time should the patient 
be sufficiently under the influence of the anesthetic to be unable to 
converse coherently or intelligently answer the questions put to him. 

It must be remembered that any anesthetic has its dangers, par- 
ticularly when its use is abused, but the above method can be recom- 
mended as comparatively safe. One writer reports its use in over 
20,000 cases without ill effects. It is true that a large per cent of 
the cases wherein death has resulted from the administration of 
chloroform or ether have occurred in the first few breaths, as we 
believe due to a strong mixture used at first or before the nerve 
filaments of the air passages have been anesthetized. 

If a few breaths administered as above, by the open method, proved 
fatal, literature would be replete with long accounts of druggists, 
lihysicians, dentists and others having met death by smelling of 
opened bottles of these drugs. 

Rapid Breathing as a means of producing peripheral anesthesia 
should receive consideration, not only for hypersensitiveness of the 
dentine but for other minor dental operations as the use of hypo- 
dermic needle, lancing of abscesses and extraction of teeth. The 
anesthetic effect is brought about by super oxidization within the tis- 
sues caused by charging the blood with an abundance of oxygen. 

This Method Is Employed by instructing the patient to take 
deep, long breaths as rapidly as possible and continue the same until 
a sense of dizziness is brought on, when from thirty to sixty seconds 
of the anesthetized condition will be found available for operating. 

Mechanical Conditions. 

The Mechanical Conditions under which the cutting of dentnie 
is done is a great factor in the amount of pain produced. 

Sharp instruments which cut without pressure upon the contents 
of the tubuli cause much less pain than dull ones even with hand 
instruments. With rapidly revolving engine burs this is also true 
to say nothing of the heat produced by the friction caused by rub- 
bing surfaces which are worn away rather than cut, which is the 
chief source of pain in the use of burs. 

The Cutting Should Be Done as much as possible at a right angle 
to the long axis of the tubules rather than to follow their course with 
pressure towards the pulp or in a line with their long axis. 



CHAPTER XXXIV. 
PEOTECTION OF THE VITAL PULP. 

The Normal Pulp has no tactile sense, neither is it responsive to 
thermal changes even though they vary considerably from the body 
temperature. 

When Robbed of Its Normal Covering and Protection the re- 
verse of the above conditions quickly develops. The sense of touch 
becomes very acute and any contact with foreign substances causes 
great pain. This is best illustrated when a tooth is broken through 
its crown by a blow, thus exposing the pulp. At first the pulp may 
be touched with the finger or an instrument without the knowledge 
of the patient but in a very few minutes the same will cause unbear- 
able pain. Also at first the cold air does not affect the pulp, but, co- 
incident with the development of the tactile sense, comes a repug- 
nance to the cold. 

The Chief Idiosyncrasy of the Pulp is its response to thermal 
changes and especially to cold, when these changes are rapid or the 
pulp is in any Avay hyperemic. A normal pulp will tolerate with- 
out response quite a range of temperature when the change is brought 
about slowly. This is generally the case when the pulp is covered 
with the full crown of the tooth. But when, through decay or other 
causes, this covering is all or partially lost, the changes are so rapid 
that the peculiar responsive features spoken of are developed. 

The Recuperative Powers of the Pulp are very slight, the least 
of the soft tissues of the body, as it will regain a healthy condition 
from only the initial stages of disease. It "^\'ill many times make 
a feeble effort t-o protect itself when the irritation is mild by filling 
up the dental tubuli with calcic matter or a secondary construction 
of dentine, through the activity of its odontoblastic layer of cells. 
Even this reparative process must not be vigorously inaugurated or 
the death of the pulp will result, proving that these reparative meas- 
ures on the part of the pulp are pathological, rather than physio- 
logical in nature. 

The Protection of the Pulp from its greatest enemy, sudden 
thermal changes, is most essential and as most of oui' desirable fill- 
ing materials are good conductors of heat and cold it becomes neces- 
sary to place some substance which is a poor conductor between the 
filling and the dentine, this operation being termed '^ capping the 
pulp." 

204 



PROTECTION OF THE VITAL PULP 205 

The Indications for Pulp Protection are not always clear, but will 
involve a consideration of the age of the patient, extent of loss of 
dentine, location of the cavity in the tooth, location in the mouth, 
length of time the pulp has been exposed, the stage of hyperemia, 
the general health of the patient and the possibilities of pulp infec- 
tion. 

The Age of the Patient has a bearing on the successful issue of a 
conservative treatment, as the teeth of the young are more easily 
saved from further irritation through capping than are the teeth of 
those past middle age, while at the same time they demand capping 
more frequently under the same conditions. Again, the pulp should 
be saved if possible until the teeth are fully formed, and many times 
the teeth of the younger patients are badly decayed and the pulp 
in great danger before the teeth are complete, hence if the pulp can 
be conserved and devitalization avoided, it is of great good to the 
patient. 

In Advanced Age the apical openings become smaller and many 
become much contracted, barely accommodating the vessels with a 
normal flow of blood so that a very slight congestion may cause death 
from strangulation or gangrene. 

When a Large Amount of Dentine Has Been Lost, even though 
the pulp as yet seems normal, it is safe practice to avoid the plac- 
ing of the best conductors, as gold or amalgam, in close proximity 
to the pulp as repeated shocks to the pulp through the filling from 
thermal changes may bring on hyperemia of that organ. In the use 
of phosphate of zinc cement in such cases, there should be an inter- 
vening media to prevent the irritating effect of phosphoric acid. 

The Location of the Cavity is a factor in the demands for pulp 
protection, as well as the probability of success in extreme cases. 
The first portions of the pulp to show hyperemic conditions are those 
nearest to the point of irritation. These congestions are more dan- 
gerous when they appear in the body of the pulp, as they do where 
decay approaches the pulp in the gingival third. Hence, when a 
pulp is nearly exposed in this location it demands greater protection 
and is at the same time harder to save than when the horns of the 
pulp are involved. 

The Location of the Tooth should be considered. Anterior teeth 
are subject to greater extremes of heat and cold than are the molars, 
hence the demand for preventive protection with the anterior teeth 
should be remembered. At the same time their exposed position 
makes pulp-capping more hazardous and it should be practiced with 
great care in this location. Again, less risk should be taken in the 



206 OPERATIVE DENTISTRY 

capping of pulps in the anterior portion of the month as it is better 
to remove a number of questionable pnlps than to have one die in 
the tooth with its consequent discoloration. 

The Length of the Time the pulp has been exposed to the irritat- 
ing influences is to be taken into account as the shorter the time of 
exposure, the greater the probabilities of success in capping. 

The Stage of Hyperemia should be a safe criterion where there 
are actual pulp complications, as there will be in almost every deep- 
seated cavity. In active hyperemia, from causes other than bacteria, 
it is safe to protect the pulp from future irritation and insure its 
conservation. However, when the symptoms of passive hyperemia 
have developed it is not safe practice to attempt to restore the pulp 
to normal and expect permanency. 

The Symptoms of Active Hyperemia when the pulp- demands 
protection and success may be expected are: 

First — When the excavated cavity exposed to the air causes a con- 
tinued pain not of a throbbing nature and the condition is relieved 
by packing the cavity with dry cotton. 

Second — When a blast of air from the chip blower causes a quick, 
sharp, shooting pain which subsides as quickly as it came. 

Third — When the pulp shows the power of accommodation as evi- 
denced by tolerating a draft of cold air when the same is gradually 
applied. 

Fourth — When it is improbable that the pulp has become infected. 

Pulps Infected With Bacteria should be extirpated as too large 
a percentage of those exposed and capped die and thereby bring re- 
proach upon dentistry in general and chagrin to the careful operator. 

The time was when the profession attempted to conserve all por- 
tions of the pulp found to be vital, even to amputating the coronal 
portion and leaving intact the vital stumps. However, this was in 
the days of imperfect root canal treatment and filling and about as 
many abscesses followed one kind of treatment as the other. But 
at the present time the removal of a pulp is attended with such uni- 
versal success that the capping of exposed pulps, in general, is un- 
warranted, as most pulps are infected at the time of exposure. Even 
in the case of an accidental exposure in the preparation of a cavity 
neither cavity nor instruments are surgically sterile. 

The General Health of the Patient must be considered Avhen 
choosing between the conservative or radical treatment of the pulp. 
With the same conditions presented, the pulps in the teeth of the an- 
emic patient, those wherein the vital processes are at low ebb. or the 



PROTECTION OF THE VITAL PULP 207 

elimination of the vital ash is imperfect and cell metabolism is defi- 
cient, protective means of conservation are more imperative, while at 
the same time less risk should be taken in questionable cases. 

With Robust and Particularly Plethoric Patients, all inflamma- 
tory processes run a rapid and riotous course, and when the pulp 
has taken on any stage of hyperemia changes towards dissolution are 
of rapid succession. 

In Deep-Seated Cavities it is not unlikely that the thin layer of 
the dentine covering the pulp is infected and the pulp should be 
protected from the invasion by the thorough disinfection of the over- 
lying dentine by medication, previous to filling as well as placing 
next to the dentine in question and under the filling a permanent 
dressing which will exert a mildly antiseptic influence for some time 
following the operation. 

The Requirements of the Materials Used in Protective Pro- 
cedures Are: 

First — That they shall be poor conductors of heat and cold. 

Second — That they shall be non-changing in character, both as to 
consistency and bulk. 

Third — That they have no action upon the pulp. 

FourtJi — That they may be introduced into deep seated cavities 
without pressure. 

The Materials Advocated for This Purpose Are Numerous and 
the market is flooded with preparations of a secret nature which are 
warranted to save the pulp in almost any stage of dissolution, but 
the operator who pins his faith to such slipshod methods will sooner 
or later find that he has been duped and his grief is measured hy 
the extent to which he has employed these cure-all methods. 

There Are Four Distinct Classifications wherein success may be 
expected in methods of pulp protection. The treatment of each 
class is here given. 

First Class. In the Progressive Stage of Caries wherein but lit- 
tle dentine has been lost, yet a blast of air from the chip blower 
causes a quick, sharp pain, passing off as soon as the draft of air 
is checked, we find the simplest form demanding protective measures. 
This is the class most often neglected by the operator and many 
times irreparable injury is done a pulp by placing in such a cavity 
a filling of high conductivity, such as gold or amalgam. The patient 
often believes that ''cold water leaks in about the filling" and may 
visit another dentist thinking that he has a poor piece of dentistry, 
and the patient may be lost to an otherwise good operator, all through 
the neglect of what may appear to the operator as a trivial matter. 



208 OPERATIVE DENTISTRY 

The Treatment of the First Class is the thorough disinfection 
and then the application of phenol, full strength, for a few seconds, 
when the cavity should be dried and it will be found unaffected by 
the blast of air from the chip blower. The change is brought about 
by the superfi(5ial coagulation of the albumen in the exposed ends 
of the dental tubuli w^hich renders them non-conductive. 

Second Class. If, after one or two applications of the phenol as 
above, the distress from the blast of air is not relieved, or if the 
pain is continuous while the surface of the cavity is exposed to the 
air it is probably of the second class as met with in the nearer ap- 
proaches to the pulp. This class of cases demands a media interven- 
ing the dentine and the filling. 

The Treatment in the Second Class is as follows: Moisten the 
cavity with phenol and evaporate to comparative drjniess. Then 
paint the entire dentinal walls with a cavity varnish composed of 
copal and gum dammar in alcohol and ether solution. Such a prep- 
aration can be had at the dental depots or it can be prepared by the 
druggist. This should be thin and spread evenly, applying one, two 
or three coats and drying with a draft of air from the chip blower 
after each coat. When the varnish is entirely hardened the filling 
may be placed. 

Third Class. In the deep-seated stage of caries, where large 
quantities of dentine have been lost, even though the pulps may 
seem to be protected by secondary dentine that is much retracted, 
it is not safe to place a metal filling directly on the overlying den- 
tine. The lost tooth structure should in a measure be replaced with 
a material which is not a better conductor of thermal changes than 
dentine. This should be neutral as far as irritating properties are 
concerned, non-changing and should resist the force necessary to 
properly introduce the intended filling. 

The Treatment in the Third Class is as follows: Phenolize and 
dry. Varnish with the above cavity varnish and dry. Flow over 
the dentine, covering most if not all of the axial or pulpal wall, or 
both, according to the class of cavity being treated, a thin layer of 
oxyphosphate of zinc cement, being careful not to include thereunder 
any air bubbles; also apply without pressure. Then allow this to 
set to complete hardness, when the filling may be completed. In the 
three classes given above it will be noted that coagulation of the 
protoplasm in the exposed ends of the tubuli was the first step. This 
is good practice from the fact that this layer of coagulum is the 
least irritant to the remaining protoplasm of anything of which we 
have knowledge. Phenol is very limited in the extent of its action 



PROTECTION OF THE VITAL PUIiP 209 

and this layer of coagulation is very thin. Again, with this third 
class, it will be noted that in addition to the use of the phenol the 
cavity is given a coat of varnish before applying the oxyphosphate 
of zinc cement. This procedure is to prevent the irritating effects 
of the phosphoric acid, particularly while the cement is setting. 
Again, should the zinc contain any impurities their action on the 
pulp is prevented. One of the impurities of zinc is arsenic and some 
cements are thought to contain traces of this devitalizing agent. The 
cavity varnish given above is quite impervious to this element when 
it has been thoroughly hardened, a fact which should not be over- 
looked when it is desired to prevent the action of arsenic trioxide in 
a particular direction in a dental wall. 

Fourth Class. In deep-seated cavities where there is a slight 
pulp complication from thermal shock and where the thin overlying 
layer of dentine is probably infected to some depth and more deeply 
affected in the process of caries, the dentine should be subjected to 
quite a continued disinfecting process and a portion of the lost den- 
tine restored with a non-conducting material to shield the pulp from 
sudden thermal changes. 

The Treatment in the Fourth Class of cases is as follows : The 
cavity should be flooded with a non-irritating antiseptic, as campho- 
i^henique, pure beechwood creosote or oil of cloves. If sealed in the 
cavity for twenty-four hours the result will be much better. The 
cavity should be then wiped dry with absorbent cotton and a thin 
paste of a cement containing sulphate of zinc spread over the den- 
tine overlying the pulp. This paste should be thin enough to flow 
to position when coaxed with a small instrument, yet thick enough 
to prevent its spreading to surfaces not needed. Over this spread 
a layer of oxyphosphate of zinc cement and allow this to set hard be- 
fore completing the filling. 

In very questionable cases, the entire cavity may be completed 
with the cement and the patient dismissed for six months, at the end 
of Avhich time, if the pulp is found to be normal, a portion of the ce- 
ment may be removed and replaced with a more permanent ma- 
terial. 

Pulp Preservers and So-Called Mummifiers should be avoided. 
Even their name is misleading and such preparations are used with- 
out permanent success in the majority of cases. Their use simply 
proclaims their users as unskilled laggards who will accept an un- 
certainty to avoid a little honest labor in pulp extirpation and root 
filling. The entire procedure is diabolical and cannot be condemned 



210 OPERATR-E DENTISTRY 

in too severe terms as a retrogression in dentistry, unskilled in prin- 
ciple and unwarranted in practice. 

Gutta-Percha as a Protecting Covering is not a success from the 
fact of its great range of contraction and expansion under varying 
thermal changes. When enclosed under a perfectly tight and un- 
yielding filling, as all fillings should be. the change in bulk must 
have a piston-like effect upon the contents of the dental tubuli result- 
ing in continued irritation. 



CHAPTER XXXV. 
PULP DEVITALIZATION AND REMOVAL. 

The Reason for Devitalization and Removal of a pulp is its pres- 
ent unhealthy condition or when its future health is in danger, on 
account of environment in the way of dental operations. 

There Are Two General Causes of diseased pulps. 

First. That succession of tissue changes which has its origin in 
active hyperemia and its end in death due to the presence of bacteria 
or their products — inflammation. 

Second. Reparative congestion, due to traumatic injurj^, abnor- 
mal thermal stimuli, lack of normal thermal stimuli and peripheral 
nerve irritation. 

Bacteria and Their Products may enter the pulp tissue either 
through a loss of its normal covering, the dentine, as in the case of 
deep-seated caries, or through the general circulation by way of the 
apical foramen, as in pyorrhea alveolaris, or in other pus conditions 
in close proximity to the pulp vessels. We have no means of know- 
ing that a pulp thus invaded has recovered, while we have complete 
proof of their subsequent death from this cause, hence devitaliza- 
tion is indicated as soon as diagnosis is clear. 

The Removal of the Cause in reparative congestion of the pulp 
will generally suffice to save the pulp from further destruction pro- 
vided the intervention is in the stage of active hyperemia. 

The Traumatic Injuries most common in the production of pulp 
congestion are blows upon the teeth either through accident or ex- 
cessive malleting in dental operations; rapid movement by the ortho- 
dontist; abnormal stress in occlusion or articulation; malocclusion 
and abnormal movement of the tooth in its alveolus made possible 
by the loss of supporting structures. 

Abnormal Thermal Stimuli is a most potent factor in producing 
pulp congestion. The pulp is particularly and peculiarly susceptible 
to thermal changes and this idiosyncrasy is very rapidly magnified 
as the stages of congestion progress. 

The Reason for Abnormal Thermal Changes reaching the pulp 
is the loss of its natural covering, the dentine and enamel, through 
caries, erosion, abrasion or dental operations as well as the denuding 
of the root by a recession or loss of the sub-gingival structures. 

Lack of Normal Thermal Stimuli will induce a stagnated circu- 
lation with a sequela of degenerative changes within the pulp tissues, 

211 



212 OPERATIVE DENTISTRY 

resulting, many times, in the death of that organ. While the pulp 
is profoundly affected by abnormal exposure to heat and cold it is 
eminently essential to its normal physiological existence that it re- 
ceive the stimulating effects of the ranges of temperature usually 
found in food and drink while covered with the entire tooth. 

Peripheral Nerve Irritation may bring about reparative conges- 
tion within the pulp causing excessive tissue waste and a precipita- 
tion of lime salts within the pulp. There are two classes of these 
deposits, known as calcific degeneration and pulp nodules, the latter 
being the sequela of peripheral irritation, while calcific degeneration 
is the result of little local passive hyperemias with its cause related 
to abnormal thermal changes. 

The Irritation May Be in the terminal fibers of the nerves within 
the pulp where the nodules are found, or in an approximating tooth, 
or in a tooth in the same lateral half of the jaw or face. "Cases are 
reported where it is evident that the cause is even more remote than 
has been stated, it being a local expression of a general neurotic con- 
dition. 

The Requirements of a Devitalizing Agent are : 

Fwst. That the present and future health of adjacent tissues be 
maintained. 

Second. That it act painlessly. 

Tliird. That the dentine is not discolored. 

Fourth. That devitalization be accomplished promptly, resulting 
in a saving of time to both the patient and operator. 

The Methods of Pulp Devitalization practiced at this time are 
two: Surgical amputation while anesthetized and poisoning by the 
application of arsenic trioxide. 

To Determine the Method to employ in any given case requires 
an understanding of the pulp presented, its immediate surroundings, 
and results sought. Also the time at the disposal of patient and 
operator. While each of the two methods has its advantages, either 
can be so used as to meet the requirements of a satisfactory means of 
devitalization. 

Anesthetization of the Pulp is accomplished by forcing into the 
pulp either a solution of cocaine hydrochloride or novocain popularly 
known as ''pressure anesthesia." 

Anesthetization Is Indicated: 

First. When it is desired to remove a normal pulp. 

Second. When slight exposure of the pulp exists which has not 
yet reached the stage of passive hyperemia. 



PULP DEVITALIZATION AND REMOVAL 213 

Third. Pulps whose circulatory system is active, but whose ner- 
vous system is either deficient in development or is in the stages of 
neuroparalysis. Access to the tooth is a factor to be considered and 
will result in the more frequent use of this method with the anterior 
teeth. The possibility of securing a sterile field of operation must 
be considered as an advantage. 

The Technic of the Operation where a cavity exists is as f ollow^s : 
Apply the rubber dam. Excavate the affected dentine. Sterilize the 
remaining cavity. Place in the cavity over the pulp a small pellet 
of cotton saturated with either cocaine or novocain. Apply over 
this a piece of unvulcanized rubber which will approximately fill the 
cavity and with blunt instruments, as amalgam packers, gently force 
the mass in the direction of the pulp. It is essential that the rubber 
first come into contact with the cavity margins at all points, or the 
.fluid will not be confined and its escape renders the attempt a fail- 
ure. If the first pressure of the confined solution upon the pulp 
causes pain the operator should stop increasing the pressure, but 
hold the advantage gained by not releasing the pressure already ap- 
plied, when, after Avaiting a minute or two, the pressure may be in- 
creased and finally the rubber can be kneaded into the cavity with 
considerable force. Sometimes one application thus made will com- 
pletely anesthetize a pulp. However, other cases will require two 
or more applications. Between such applications the dentine should 
be removed from over the pulp to complete exposure where this can 
be done without undue pain to the patient. 

When, after two or three attempts of the above method there seems 
to be no effect obtained, it is generally best for both patient and oper- 
ator to resort to the application of arsenic, unless the case is suited 
to favor the use of the high pressure syringe. 

The High Pressure Syringe is of service where no exposure ex- 
ists, and where the necessary puncture for the introduction of the 
syringe point can be included in the filling, or Avhere the crown is 
to give place to an artificial one as an abutment for a bridge. The 
method has to recommend it speed, a certainty of preserving the 
color and is generally accomplished with little or no pain to the pa- 
tient. 

The Technic in Its Use. To the prescription given for the open 
cavity add fifteen drops of distilled water and load the syringe, see- 
ing that all joints are screwed up tight. Select a point of direct 
access either on the dentinal walls or it may be on the external enamel 
surface, preferably in the gingival third of the tooth, and drill a 
hole directly towards the pulp one millimeter in depth and as much 



214 OPERATIVE DENTISTRY 

farther as possible without causing the patient pain. The drill used 
should be smaller than the syringe point that a close fit to the hole 
may be secured. Syringes are generally constructed so that a drill 
made by flattening a No, 1-2 round bur will make a proper sized hole. 
The syringe is then applied to the opening with some pressure and 
its contents forced into the dentine. 

It is essential that the solution be perfectly imprisoned as it re- 
quires high pressure to force the anesthetic through the tubuli. Af- 
ter holding the solution at high pressure in contact with the dentine 
for one or two minutes it should be removed and the drill applied to 
the hole to test its sensitiveness. If desensitized the hole should be 
carried close to the pulp but not so far as to enter the chamber. The 
S3'ringe should be again applied and with great care, as sudden force 
may cause pain by too rapid pressure upon the pulp. 

Great Care Should Be Exercised Avhen the pulp has been thus 
nearly or quite exposed not to force into the pulp any considerable 
amount of the anesthetic as it is carried or forced beyond the apical 
foramen, from which no good can result and harm may. particularly 
if the contents of an infected pulp are forced through to the tissues 
of the pericementum. 

Pulp Extirpation by Hypodermic Injection. Pulps may be re- 
moved very quickly and without pain by injecting the solution of 
novocain as given for use in extracting teeth in Chapter XLI. 

If Correctly Done the Pulp May Be Removed or the tooth ex- 
tracted painlessly. Extreme care as to asepsis must be given. This 
danger of infection makes this method unsuited for general use, but 
applicable to cases where haste is imperative or where trouble is ex- 
perienced in the use of pressure anesthesia or arsenic devitalization. 

The Removal of an Anesthetized Pulp is accomplished by gain- 
ing access to the pulp chamber from a position which will admit of 
direct or nearly direct approach to each of the pulp canals, and mak- 
ing the opening large enough to admit light enough to see either by 
direct vision or the image in the mirror, the entire floor of the cham- 
ber. First, a smooth sterile broach is passed down each canal to the 
apex of the root, to test the completeness of the anesthetization. If 
no sensation is found the barbed broach is then passed to the apex, 
preferably an extra fine size. This should be twisted to the right 
about one complete turn and then gently drawn from the cavity, 
which should result in the amputation and removal of the entire 
pulp. This accomplished, the sides of the canal should be rasped 
with a barbed broach of a larger size to remove any shreds which 
mav adhere to the sides of the canals. 



PULP DEVITALIZATION AND REMOVAL 215 

To Check Hemorrhage, should that ensue, wash the chamber and 
canals with cold water, dry as quickly as possible, flood cavity with 
a drop of adrenalin chloride and apply a plug of dental rubber, 
pressing this into the cavity and holding it for a few minutes. Re- 
move the rubber and wash again with cold water. If hemorrhage 
continues repeat holding the adrenalin confined longer than before 
and applying a little more force. Care should be used in this pro- 
cedure as a sore tooth will result when the method has been used 
too vigorously. Again thoroughly bathe the canals with cold water 
or alcohol and dry. 

Discoloration Results from alloAving any blood to remain in con- 
tact with the dentine, even though it be only from one treatment to 
another as the iron of the hemoglobin is absorbed or forced into the 
tubuli resulting in permanent discoloration. TJie use of liydrogen 
dioxide is not good practice until the blood has been washed from 
the dentinal walls as it oxidizes the iron of the hemoglobin and dis- 
coloration will result. 

Post-Extirpation Pains may be prevented by pumping into the 
canals phenol with a smooth broach continuing this until the nerve 
stump at the foramen is bathed with this agent. This also has the 
effect of coagulating the mouths of the dental tubuli, resulting in 
sealing them to agents which may cause discoloration. 

It Is the Best Practice to Dress the Canal or Canals for a few 
days with a stimulating anodyne which is at least mildly antiseptic, 
as the anesthetizing of the pulp has probably so much affected the 
tissues in the apical space that there is nothing to guide us in prop- 
erly filling the pulp canals. 

Immediate Canal Filling in these cases is sometimes practiced 
where lack of time demands a hurried completion of the case and 
is quite successfully accomplished where all is just right. But so 
many times ideal conditions for canal filling are not obtainable that 
its universal practice is condemned. However, if there is to be im- 
mediate canal filling the pulp canals should be bathed with water 
and dried with warm air, flooded with phenol and again dried, this 
time with the aid of absolute alcohol, when the canal filling may be 
introduced as outlined in the chapter on ''The Filling of Pulp 
Canals. ' ' 

Devitalization With Arsenic Trioxide is the method in most fre- 
quent use and although not always to be preferred to anesthetiza- 
tion, it may be used in almost any case with satisfactory results. 

Arsenic Should Be Combined With Some Agent to allay the pain 



216 OPERATIVE DENTISTRY 

caused by its application as it is a most powerful escharotic and 
the clear arsenic applied to a pulp will often cause great pain. One 
of the most popular mixtures is here given: 

Arsenic trioxide gr. v. 

Cocaine gr. xv. 

Creosote Q. S. ft. stiff paste. 

To this should be added enough lamp black to make the above a 
dark gray color so that it will have a contrasting color with that of 
the tooth to assist in placing it in the exact location desired. 

The Technic of its application is as follows : The cavity should 
be thoroughly protected and dried, preferably under the rubber dam. 
Foreign matter should be removed from the cavity and the same 
thoroughly sterilized, the softened dentine removed and the pulp ap- 
proached to as near exposure as possible Avithout causing the patient 
pain. Complete exposure is not necessary. Again sterilize the cavity 
and dry. Bathe cavity with phenol and again dry. With the enamel 
hatchets secure a definite cavity margin, particularly if cavity is in 
the gingival third. In cavities that are sub-gingival build in amal- 
gam as high as the gum line or at least one or two millimeters high, 
being sure not to let this approach the pulp exposure or the point 
where the application is to be made. Take, of the above paste on 
the point of a flat excavator, a quantity equal to about one-fourth 
the size of a common pin head and apply very close to, but not di- 
rectly on the exposed pulp. By very close is meant within one-half 
millimeter. Place over this a piece of spunk the size of a pin head, 
or larger if cavity is large and roomy, which has been dipped in 
creosote and then pinched in a napkin to dryness, putting into place 
in such a manner as not to cause pressure on the pulp. The retain- 
ing filling may now be completed with amalgam, cement or temporary 
stopping. 

Amalgam as a Retainer of arsenic has the advantages of making 
a tight filling at the margins. Nothing will pass through it and it 
is the most easily removed if it is applied where there are frail over- 
hanging enamel walls which a chisel will easily cleave; or if the 
amalgam has been but partially mixed with not enough mercury, 
resulting in a mealy filling or where a great excess of mercury has 
been used, that is to say where a most poorly manipulated amalgam 
has been used resulting in its being cut with a bur much more easily 
than cement, an advantage in cases where a tooth becomes sore to 
percussion. 



PULP DEVITALIZATION AND REMOVAL 217 

Cement as a Retainer of arsenic has the advantage of settiniL^ 
quickly, thus removing the danger, in occlusal cavities, of the pa- 
tients causing themselves pain by biting on the fillings and produc- 
ing pressure on the pulp. With anterior teeth it is more sightly 
than amalgam or stopping. Its only disadvantage is that it some- 
times sets so well that it is hard to remove and its adhering proper- 
ties may result in dragging or lifting the application from its place- 
ment, during the manipulation of introduction. 

Temporary Stopping- as a Retainer of arsenic has to recommend 
it the ease of its removal with warmed instruments and especially 
if its surface has been treated with a blast of warm air. The dan- 
gers in its use lie in the difficulty in preventing pressure upon the 
pulp either when applied or in mastication. 

Cotton as a Retainer of arsenic should be entirely discontinued 
as it has nothing to recommend it and everything to condemn it. 

Caution in the Use of Arsenic about the teeth is of great impor- 
tance and when used it must be sealed in the dry cavity absolutely 
moisture proof and particularly when any of the cavity outline is 
sub-gingival as any leakage at this point will result in great destruc- 
tion to the gums and alveolar process. Such accidents are all too 
frequent and the injury thus done is never fully repaired. 

The Lengfth of Time an Arsenical application should be left in 
the tooth is most uncertain and there seems to be no set rule. Neither 
the condition of the pulp nor the amount of dentine intervening can 
be taken as certain in judging the time. However it is most com- 
mon practice to see the case in about one week's time, as in this 
time a majority of the cases will have become devitalized and the 
natural process of exfoliation has taken place between the dead pulp 
and the living tissues at the apex of the root enabling the operator 
to remove the pulp without pain or hemorrhage. 

Primary Soreness of the Tooth to percussion generally indicates 
the death of the pulp. If an attempt is made to remove the pulp 
too soon great pain will result as the pulp is yet vital, hence it is 
best to wait until the pulp has been fully affected. Again during 
the primary soreness and particularly during the first twenty-four 
hours of this condition the patient cannot tolerate the instrumenta- 
tion necessary. Such cases should be left from twenty-four to 
forty-eight hours from the time pericemental soreness develops, hav- 
ing applied to the gum over the afflicted tooth aconite and iodine 
when it will generally permit of treatment. 

Secondary Pericementitis is dangerous to the sub-dental tissues 



218 OPERATIVE DENTISTRY 

and no arsenical application should be allowed to remain until this 
second attack appears, as the loss of the tooth is not beyond the pos- 
sibilities of such neglect. 

The Treatment of Arsenical Poisoning due to its escape from the 
cavity is as follows: Remove everything from the tooth cavity. 
Hood the cavity and destroj^ed tissues with a forceful stream of 
tepid water to remove all traces of the arsenic not yet absorbed. 
With a sterile spoon excavator dissect and curet away all necrotic 
tissue continuing until hemorrhage is produced. Again flood the 
parts with warm water. Dry with a cotton ball and lightly paint 
the wound with aconite and iodine, repeating the treatment every 
other daj^ until a healing is effected. 

When Pulp Returns Partially Devitalized as is evidenced by sen- 
sation, particularly in the apical third of the canal, it is best to open 
the pulp chamber and amputate with a sharp spoon excavator only 
the coronal portion. AVash chamber with warm water and dry Avith 
warm air. Apply absolute alcohol working same towards the apex 
by the side of the pulp as far as possible without causing pain, fol- 
lowing this with thorough desiccation with warm air. Then seal in 
a dressing of phenol and dismiss for one week or even longer and 
the case will usually return with devitalization complete. This treat- 
ment is particularly indicated in young teeth where the apical fora- 
men is large. 

The Removal of the Pulp following arsenical devitalization is 
practically the same as that following anesthetization., except that in 
the latter case there is danger of going beyond the apex, while with 
the arsenic devitalization method, the greater danger is in not ex- 
tirpating the pulp entirely to the apex through mistaking a vital 
pulp stump within the canal for vital tissue beyond. 

Immediate Canal Filling following arsenical devitalization is 
quite universally practiced and is generally satisfactory. However, 
too large a per cent is followed by mild or severe pericementitis, 
v/hich might be averted by dressing the canals with a mildly anti- 
septic anodyne of a stimulating nature for a few days before filling 
the pulp canals. 

All Treatments Above Referred To in this chapter should be 
carried out with the rubber dam in place at each sitting. (See chap- 
ter on ''The Filling of Pulp Canals.'') 



CHAPTER XXXVI. 
MANAGEMENT OF PUTKESCENT PULP CANALS. 

By ''Putrescent Pulp Canals" is meant that condition in these 
spaces resulting from putrefaction. 

By ''Putrefaction" is meant that serial, progressive decomposi- 
tion through which albuminous substances are finally resolved into 
the end-products, hydrogen sulphid (H2S), carbon dioxide (CO2), 
ammonia (NH3), water (HoO), and hydrogen phosphid (PH3). A 
distinguishing feature of the process is the evolution of malodorous 
gases. 

The Presence of Bacteria is necessary to the process of putrefac- 
tion and all such cases must be approached with this fact in mind, 
and antiseptic measures and precautions are paramount from the 
beginning of the case to its termination, that the pericementum may 
not be involved in the destructive process. 

There Are Four Classes of Putrescent Pulp Canals, according to 
the manner in which they are presented, symptoms present and the 
method of treatment. 

First. Those cases where the canals are open and exposed to 
the fluids of the mouth known as "open putrescence" and which are 
generally the result of the encroachment of caries. 

Second. Those cases wherein the pulps die under a filling or a 
layer of affected and infected dentine, the integrity of which will 
not permit of the passage of fluids or gases. This is known as 
"closed putrescence" and is the result of extrinsic infection. 

Tliird. Those cases wherein the crown is integral and the bac- 
teria necessary to putrefaction have entered the pulp tissue either be- 
fore or after its death by way of the apical foramen, conveyed there 
by the circulation of the blood. This class of cases, from the ap- 
parent autopathy is termed "autogenous putrescence." Such cases 
are most likely to follow suppurative processes in close proximity to 
the arteries leading to the pulp, yet cases are seen where no such con- 
ditions can be diagnosed, primary to the pulp symptoms, and are 
generally traumatic. 

FourtJi. Those cases wherein the destructive processes have been 
communicated to the pericementum, and are known as "complicated 
putrescence." There may be pericemental inflammation in any of 
its stages with or without soreness to percussion. The apical space 
may harbor pus without other communication than the putrescent 

219 



220 OPERATIVE DENTISTRY 

pulp canal or there may be an abscess with a sinus passing through 
the alveolar process and opening through the gum. 

Treatment in General may be stated as involving the removal by 
mechanical and chemical means of all products of putrefaction, thor- 
ough sterilization of all surfaces exposed, conservation of vital tis- 
sues beyond the apical foramen and the permanent closure of the 
foramen to the passage of fluids and gases. 

The Symptoms of Open Putrescence (Class One) are not marked 
where the pulp is entirely putrescent, unless there are pericemental 
complications, when the case would come under the heading of com- 
plicated putrescence. "When a portion of the pulp is yet vital it is 
probable that the pulp is undergoing a cellular disintegration through 
surface ulceration. This is usually a painless process and is re- 
sponsive only to the encroachment of foreign substances which lacer- 
ate its tissues or produce pressure within its substance.- Such cases 
call for sterilization and extirpation. However, with simple open 
putrescence the symptoms are largely objective, the operator dis- 
covering the conditions through instrumentation, and the noxious 
gases encountered. 

Treatment of Open Putrescence. Excavate the cavity to com- 
plete exposure of the pulp chamber. Flood with a stream of water 
from the syringe. Apply the rubber dam and sterilize all teeth and 
surfaces exposed. For this purpose use a ten per cent solution of 
formaldehyde to which has been added a small amount of borax. 
Another efficient sterilizing agent is bichloride of mercury, in the 
proportion of one part to five-hundred of cinnamon water. Mechan- 
ically remove the contents of the pulp chamber and flood the open 
cavity with hydrogen dioxide, repeating the dioxogen two or three 
times or until active effervescence ceases. Apply absolute alcohol 
and evaporate to complete dryness. With an extra fine barbed broach 
mechanically clean each root canal Avith hydrogen dioxide. Care 
should be taken not to force any of the putrescent matter through 
the foramen. Eemove the contents of the canal, portion by portion. 
The canals should then be dried with alcohol evaporation. Follow 
this with a fifty per cent solution of sulphuric acid which is allowed 
to remain three or four minutes when it should be thoroughly diluted 
with water and the canals dried. Apply campho-phenique and desic- 
cate to dryness. For the final dressing flood with phenol, pumping 
it to the apex of said canal with a smooth broach. To this add a 
paste made by mixing iodoform with phenol sufficiently stiff to be 
handled to the cavity on a large spoon excavator. If crystallization 
takes place add a drop of water. Avoid glycerine or alcohol. By a 



MANAGEMENT OF PUTRESCENT PULP CANALS 221 

pumping motion of the broach the paste will be thinned and follow 
the phenol already in the canal to the apex. 

By alternately adding the paste and absorbing the excess phenol 
the canal can be filled with a comparatively thick paste. Fill the 
pulp chamber with a pellet of dry cotton. Seal the cavity with tem- 
porary stopping or cement, preferably for a week or ten days, when 
the case will almost invariably return ready for permanent canal 
filling. If a shred of vital pulp is encountered in the apical third 
it will have been devitalized by the phenol and that without pain or 
noticeable soreness. 

The Chief Objection to This Form of Treatment is the obnoxious 
odor of the iodoform. The deodorized preparations, however, will 
not accomplish the desired results. Care should be taken that the 
iodoform is kept moist at all times and finally deposited in the foun- 
tain spittoon. Each teacher has a different treatment for putrescence 
and the student is advised to familiarize himself with all. However 
the above is a one-sitting, successful treatment and its trial is ad- 
vised particularly where other methods have resulted in pain to the 
patient and oft-repeated visits to the dental chair. 

In Cases of Long Standing Putrescence, which are generally open 
cases, the dentine is thoroughly saturated with poisonous ptomaines, 
amido acids and end products. These must be gotten rid of and 
the most expedient method is to chemically change these irritating 
gases and poisonous liquids into non-irritating and non-poisoning 
liquids and solids. This is most successfully done through the use 
of formaldehyde. Formaldehyde, however, is very irritating to vital 
tissues and should not be brought into contact with them. There- 
fore its use is contraindicated in cases of large apical foramen. Also 
not indicated in cases where a portion of the vital pulp remains, as 
many times intense pain will be induced. To modify the irritating 
effects there may be added to a ten per cent solution of formalde- 
hyde an equal bulk of either phenol, creosote, or creosol, the latter 
being preferable. This should be sealed in the cavity and crown ends 
of the canals for twenty-four or forty-eight hours before thorough 
broaching of the canals is attempted. Following the removal of the 
above treatment the canals should receive a bath first of water and 
then of alcohol to carry away in solution the compounds resulting 
from the chemical action of the formaldehyde. 

Animal Fats, w^hich consist of carbon, hydrogen and oxygen, are 
liable to be present in abundance in recent cases of putrescence and 
should be removed from the dentinal walls as they readily undergo 
fermentative decomposition. 



222 OPERATIVE DENTISTRY 

Their Removal Is Best Accomplished by saponification through 
the action of sodium dioxide. This should be applied at the time of 
broaching the canals, using a platinum broach. Following its use 
the canals should receive a water bath. 

Symptoms of Closed Putrescence (Class Two). Closed putres- 
cence without complications is usually of short duration and when 
they are presented for treatment before complication there generally 
remains a portion of the pulp in the apical region yet vital. 

The chief pathognomonic sjTnptom is that heat produces paroxysms 
of pain while cold applications bring relief. 

The Treatment for Closed Putrescence is to apply the rubber dam 
and with a small drill open directly to the pulp chamber when tem- 
porary relief will be immediate. The opening should then be en- 
larged and the necrotic pulp tissue removed. If no vital pulp tis- 
sue is found the case should be proceeded with as before outlined 
for cases of open putrescence. AYlien a vital portion of the pulp re- 
mains nothing will be more palliative than the phenol and iodoform 
paste treatment already outlined. This paste will also devitalize the 
remaining portion of the pulp. Pressure anesthesia is certainly not 
indicated in such cases from the liability of infecting the pericemen- 
tum. Neither is an arsenical application permissible within a pulp 
canal, hence the phenol treatment is the best practice. 

Autogenous Putrescence of the Pulp (Class Three) are occasion- 
ally met Avith and may be of long standing without complications of 
the apical tissues and only discovered when the dentine of the crown 
is found to be non-vital. Such cases are generally of traumatic 
origin primarily, the putrescent condition developing long after the 
death of the pulp by the egress through the apical foramen of 
facultative anaerobic bacteria. Such cases are dealt with, when 
treated, as any case of closed putrescence, excepting that extra 
precaution as to access must be taken as the admittance of the 
air to such cases seems to render the putrescent matter most viru- 
lent and the dangers of complications are most extreme. Cases pre- 
sented, of recent origin, which may be classed as autogenous are 
generally complicated when they come to the dentist as the com- 
plication is the cause of the patient's visit, when they would be 
classed as a case of closed putrescence. Their cause is the en- 
trance of infection through the circulation, the bacteria having 
been picked up in pus areas not far distant from the apical fora- 
men. Strictly speaking there are no autogenous diseases or condi- 
tions, such as auto-infection as all in this life is the result of ex- 



MANAGEMENT OF PUTRESCENT PULP CANALS 223 

trinsic causes more or less remote from the body but the classifica- 
tion of autogenous putrescence of the pulp is given, based upon 
the same theories and principles as those applied in general 
pathology, wherein the immediate cause is not at all apparent. 

The Symptoms of Complicated Putrescence (Class Four) vary 
from slight soreness to percussion to the symptoms accompanying 
most violent and acute inflammatory processes even with general 
febrile disturbances. Other cases will present themselves with an 
entire absence of all the above symptoms, the only evidence of 
pericemental complications being detected b}^ observation or in- 
strumentation. It is generally true that the acute cases show the 
more marked symptoms, and the extremes of easy and difficult 
management are encountered, whereas Avith chronic complications 
the symptoms are not so marked and generally yield to stereo- 
typed methods of treatment except where great destruction of tis- 
sue has taken place, Avhere such cases should come under the head 
of surgery. 

The Treatment in Complicated Putrescence is as varied as the 
sj'mptoms presented and the conditions found. The first order of 
procedure is the removal of the cause which includes the elimina- 
tion of the putrescent conditions Avithin the pulp canal under 
aseptic precautions. If the pericementum is only inflamed and the 
presence of pus is not probable, the treatment is the same as that 
outlined for uncomplicated putrescence, adding external applica- 
tions to the gum over the affected tooth to stimulate resolution. 
Painting with aconite and iodine is suggested. 

In Acute Complication where pus has formed and upon broach- 
ing is freely evacuated dovrn the pulp canal, it is the best of sur- 
gery to allow free drainage by this route for twenty-four or forty- 
eight hours before attempting further treatment. At the end of 
this time the most active symptoms will have generally subsided 
and the case can be proceeded with. However, there have been 
some cases so deeply affected beyond the apex of the tooth that ex- 
ternal pointing on the alveolar wall is probable and only avoided 
by immediate extraction of the tooth. In such cases the salvage of 
the tooth depends upon the ability of the patient to withstand the 
pain to the termination. They may be assisted in this through the 
general administration of sedatives. Locally the application of re- 
T^ulsives to the gum will hasten the external pointing. Evacuation 
ushers in the stage of convalescence and the treatment of the pulp 
canals may be proceeded with. 



224 OPERATIVE DENTISTRY 

In Chronic Complications of Putrescence Avhere the drainage is 
through the pulp canal only, the case may ans^ver to the treat- 
ment of the pulp canal. However other cases will demand special 
treatment for tjie sterilization of the enclosed pocket beyond the 
foramen. The greatest danger in the treatment of this class is in 
suddenly converting them into acute form. This can generally be 
avoided by attempting the treatment of the sub-dental conditions 
only following complete and absolute sterilization of the communi- 
cating canal. That there is a communicating canal in these cases 
of so-called ''blind abscesses" is self-evident and this opening per- 
mits of treatment without the use of pulp canal drills, a method 
Avhich is not advised and a practice w^hoUy unwarranted, result- 
ing, many times, in rendering the case beyond the possibilities of 
cure. 

If the case must have additional drainage it is a case of surgi- 
cal procedure and the point of attack should be through the ex- 
ternal alveolar wall, a method sometimes resorted to with good re- 
sults. 

Chronic Alveolar Abscess With Sinus, generally Avith the opening 
on the external alveolar wall, is a complication resulting from a 
closed case of putrescence of long standing and when not associated 
with necrosis or denuded root is not, as a rule, hard to manage. 

The Treatment of Chronic Alveolar Abscess is to thoroughly 
sterilize the pulp canal, then the fistulous tract. The tract should 
be established by forcing hamamelis or cassia water through the 
pulp canal and out through the sinus. Follow this with phenol or 
aconite and iodine only sufficient to cauterize the entire surface of 
the tract thus destroying the fibrous lining, improperly called the 
'^pyogenic ynemhrane.'' Then proceed as with any other case of 
putrescence, filling the pulp canal before closure of the sinus has 
been effected. Some advise the entire treatment and canal filling 
at the first sitting, but it is probable that better results will be ob- 
tained if case is allowed a Aveek or ten days betAveen the first 
treatment and the canal filling for complete sterilization of the 
dentine Avails. 



CHAPTER XXXVII. 
THE FILLING OF PULP CANALS. 

It Is Necessary to Fill Pulp Canals following the removal of the 
pulp, to prevent the exit of bacteria or their products to the tis- 
sues bej^ond the foramen, and to prevent the dissolution of the en- 
compassing walls of dentine. 

A Pulp Canal Is Ready for, and should receive the root filling 
when the canal is void of all else than air and it is not desired to 
again reach the pericemental tissues for treatment. To render a 
canal void of all else than air is by no means universally easy, yet 
it is the object sought and the conditions are not ideal until this 
result is obtained. This involves the removal of all pulp tissue, 
moisture, bacteria and their products as well as all medicines and 
chemicals used in the process of treatment. 

The Perfect Pulp Canal Filling is one which permanently occu- 
pies the entire space of the pulp canal and closes the apical fora- 
men to the exit or entrance of all substances, particularly gases 
and fluids. 

The Requirements of a Material for Filling a Pulp Canal are 
that it be non-soluble in the fluids of the body, that it be non-irri- 
tating to soft tissues, permanent as to bulk and consistency, not 
subject to putrefaction or chemical changes, capable of easy intro- 
duction, and it is an additional virtue if it can be again removed 
from the canal after months or even years of occupancy. 

The Objective Point in Pulp Canal Filling is in the region of the 
foramen. This point must be reached, made surgically and thera- 
peutically clean, completelj'' vacated and then permanently sealed 
with a suitable material. 

Small Pulp Canals and particularly if they are tortuous, are a 
hindrance to always attaining ideal results and even, in rare cases, 
thwart effort to save teeth thus afflicted. 

The Means of Cleansing and Vacating small and tortuous canals 
are both mechanical and chemical. 

It Is Best Accomplished mechanically by the use of small, flex- 
ible, blunt-pointed twisted reamers, which enlarge the canal to the 
extent of entrance by cutting away the sides to increase their cal- 
iber until broaches of other forms will be admitted. This process 
is assisted chemically by flooding the canal with a fifty per cent 

225 



226 OPERATIVE DENTISTRY 

solution of sulphuric acid, as this will dissolve and soften the den- 
tinal walls, thus facilitating the enlargement of the canals. 

In Cases Where the Root Is Bent on Its Long Axis it is essential 
that the broagh should be rounded and blunt of point that it may 
follow the canal and not cut its side wall at the bend of the canal, 
which will produce a shoulder and hinder further progress. This 
is essential with the finest of broaches and requires preparation on 
the part of the dentist of every broach used in this class of work, 
as all broaches that come from the factory have a very sharp point 
entirely unfitting them for opening crooked pulp canals. This 
blunting process is best accomplished by holding the end of the 
broach at an obtuse angle on the face of a fine cuttle fish disk while 
revolving in a dental engine, at the same time tAvisting the broach 
from right to left. 

The Carrying of Cotton into a Pulp Canal is of assistance in the 
drying process and requires the special preparation of a broach to 
facilitate the application. 

The Cotton-Carrying Broach is prepared by taking a perfectly 
smooth fine hook broach and by grasping Avith a pair of flat-nosed 
pliers, say the sixty-fourth part of an inch from the end, rocking 
the pliers back and forth until the end is broken off. This results 
in a blunt broken surface on the end Avhich engages the fibers of 
the cotton twist and prevents same from slipping up the broach 
toAvards the handle, as it is introduced into the canal, allowing the 
cotton to be carried to the depth that the caliber of the canal Avill 
permit. 

The Cotton Is Applied to the broach by taking a fcAv fibers be- 
tAveen the thumb and first finger, placing around the broach, 
tAvisting the handle of the broach to the right, and at the same 
time moving the thumb and finger to roll the broach in the same 
direction. The use of Red Cross absorbent points is better 
practice. 

If It Is Intended to Leave the Cotton in the Canal as a dressing, 
loll upon the broach tightly at the point only, and Avhen introduced 
io the entire depth of the canal tAA'ist the broach to the left part of 
a turn and use a tamping motion, and the cotton Avill be disen- 
gaged and packed in the canal. 

If It Is Intended to Remove the Cotton With the Broach, roll 
tightly its entire length and when the cotton is being introduced, 
as well as during withdraAval, tAA'ist the broach to the right con- 
tinuoush' as this Avill cause the broach to maintain a tisfht hold on 



THE FILLING OF PULP CANALS 227 

the cotton. When all has been removed grasp the cotton between 
the fingers, twist broach to the left and cotton is easily disengaged. 

The Most Popular Root Filling of today is gutta-percha, a por- 
tion of which is dissolved in chloroform to facilitate its introduc- 
tion. However the less amount of chloroform or any other fluid 
there is in the finally completed filling, the better, as these constit- 
uents are not permanent. 

Methods of Use. The canal must be entirely vacant except the 
air which it contains, for its entire length, not forgetting that this 
includes the removal of all moisture possible. 

The First Step Is to Replace This Air wdth a fluid that is a sol- 
vent for the gutta-percha canal filling. A very popular substance 
for this purpose is the oil of eucalyptol as this, in addition to being 
a solvent for gutta-percha, is slightly antiseptic and, being an oil, 
does not mix with any blood serum or moisture that has, per- 
chance, escaped the operator's notice in the apical end of the 
canal, or may have a tendency by capillary attraction to exude 
into the mouth of the foramen, floating the same from the walls. 

The Introduction of Chlora-Percha is accomplished by dipping 
a small broach into the container and carrying the broach thus 
loaded, to each canal. Carry same to the foramen and by a pump- 
ing motion the chlora-percha is mixed with the eucalyptol, and no 
air or moisture will be imprisoned within the canal. 

The Introduction of the Gutta-Percha Canal Point is here ac- 
complished by grasping the large end, w^hich may be flattened 
with the cotton pliers or attaching same to the warmed end of a 
canal plugger, then withdraAving the smooth broach w^hich has 
been allowed to remain part way up the canal and immediately 
entering the small end of the canal point and shoving entirely to 
place by a steady gentle pressure. 

The Size of the Canal Point should be great enough to entirely 
fill the canal. It should be about a millimeter longer to permit of 
slight tamping at the mouth of the canal. The size may have been 
previously ascertained by measurement and trial, w^hich is good 
practice for a beginner. An experienced operator will, in most 
instances, be able to judge as to size without measurement. 

Slight Flinching on the part of the patient or the sense of full- 
ness is quite a trustworthy guide as to having reached the apical 
end of canal in recent cases of devitalization, but such symptoms 
should not be sought in devitalized teeth of long standing, partic- 
ularly if there has been a loss of any of the tissue in the apical 
space. However, in these cases as with all others, care should be 



228 OPERATIVE DENTISTRY 

taken that perfect and complete filling of the apical foramen has 
been accomplished, ^vhich is ideal. Yet to fill slightly beyond the 
canal by a fraction of a millimeter is a less error than to not en- 
tirely fill the canal. The opening of the canal should now be 
tamped solid, which process is aided by warming the protruding 
end of the canal point. 

Cleanse Pulp Chamber of all traces of gutta-percha and case is 
ready for final operation. 

Tlie practice of filling pulp cliamhers ivith gufta-perclia in any 
form is condemned as it is in no way suitable for the seat of a fill- 
ing. Cement, amalgam or tin is preferable. 



CHAPTER XXXVIIl. 
MANAGEMENT OF CHILDREN'S TEETH. 

The management of children's teeth presents two difficulties ad- 
ditional to the management of the teeth of adults. 

The First Difficulty and many times the most important is the 
management of the child. Children are very susceptible to exter- 
nal influence and even when quite young believe all they hear. 
The conversation of the older ones about the home pertaining to 
the ''horrors" of the dental office, has many times so poisoned the 
mind of the child that it prejudges the dentist and his efforts to 
the extent of preferring any other punishment rather than meet 
the dentist, even for an examination. 

The First Visit of a Child should be made one, wherein there is 
an entire absence of pain, or even inconvenience on the part of the 
child. 

Such visits should be repeated till absolute confidence has been 
secured. After this has been thoroughly established, the children 
of a clientele will prove as easil}^ managed as the adults, and in 
after years are the most tenacious patrons, seldom changing their 
dentist through life. 

The Second Difficulty with the management of deciduous teeth 
is the comparatively short life of the most careful operations. The 
teeth are themselves but temporary. All about them is a panorama 
of change and we can hope at best for only temporary results. 
Parents should be given to understand this feature of the services 
and not be led to misjudge the skill of an operator by the results 
of operations on the teeth of children. 

Early Attention is imperatiA^e and the keynote to success. All 
small enamel defects should be sought out and fillings made as 
soon as such are found to exist. It is hopeless to attempt the sal- 
vage of deciduous teeth after the pulps have become involved and 
subdental disorders have been established. 

Oral Hygiene With Children should be established early. The 
parents should receive thorough instructions as to the use of the 
toothbrush, with or without a dentifrice, as the child prefers, and 
a daily attention established by the time the full temporary den- 
ture is erupted. 

Frequent Visits to the Dentist are essential; even more than 
with adults, as the destructive process runs a rapid course when 

229 



230 OPERATIVE DENTISTRY 

once established, a few weeks' neglect often resulting in irrepara- 
ble injury. These visits should be established at regular and fre- 
quent intervals, as the most unhygienic conditions may result from 
only a few days', neglect and upon early detection and eradication 
depends the success of interference. 

Length of Time at Each Sitting should not exceed thirty min- 
utes for a child under twelve years of age and should not exceed 
one hour until after eighteen years of age. Great care should be 
exercised in causing the child any considerable amount of pain. 
Better that the filling consist of temporary stopping to last but a 
few days than to cause lasting memories of dental pains inflicted 
by the dentist. 

The Filling Materials to Be Used are limited to those of speedy 
manipulation, and those requiring a minimum of convenience 
form. This will place in the list, amalgam, tin, gutta-percha and 
cements. 

Cavity Preparation should be limited to the removal of the ma- 
jor portion of decay, sterilization and securing the cleavage of the , 
enamel in cavit}^ outline by the use of the chisel. All else should 
be avoided. 

Extension for Prevention, Extension for Resistance, Flat Seats 
for Fillings, Line Angles and Point Angles and all else in cavity 
preparation so carefully applied to filling the teeth of adults 
should be ignored when dealing with deciduous teeth. If decay 
has not left the cavity naturally retentive, cement should be re- 
sorted to instead of cutting. 

Cavities of Class One. Pit and fissure should be filled with 
amalgam or tin under as dry conditions as can be secured without 
the rubber dam. The use of the rubber dam should be restricted 
to the six anterior superior teeth and when used should be very 
loosely ligatured. 

Cavities of Class Two. Proximal cavities in molars should be 
filled with amalgam. When the retentive form is not good in the 
cavity Avithout much cutting, the amalgam should be laid in soft 
cement. 

When Two Cavities Exist in molar proximal space which are 
not retentive it is good practice to fill the tAvo cavities as one, 
counting on refilling the cavity in the second molar if the first 
molar is lost early, or perchance when this has failed, which it will 
sooner or later, the cavities will return Avith independent retentive 
form. 



MANAGEMENT OF CHILDREN'S TEETH 231 

Cavities of Class Three should be filled with cement with rubber 
dam in position. If decaj^ has progressed till angle is lost or par- 
tially so, do not build to contour but fill as a Class Three. 

Classes Four, Five and Six may be ignored. 

Treatment of Exposed Pulps in Deciduous Teeth. Pulp devital- 
ization with deciduous teeth should never be attempted. Pressure 
anesthesia will not prove successful. Arsenic should never be ap- 
plied to deciduous teeth. The risk is too great and is condemned 
in every case. If the pulp is exposed and aching, clean out the 
debris, flood Avith warm Avater, dry and phenolize. Apply a pledget 
of cotton saturated with oil of cloves for twenty-four hours. 
AVhen case returns, dry and again phenolize and apply a paste of 
phenolized iodoform over which place a filling. 

If the pulp has begun to suppurate, the necrosed tissue should 
be cut away and the space filled with a paste made of oil of cloves 
and the oxide of zinc powder, over which is placed a filling of tem- 
X)orary stopping. The pulp will usually die under this without 
further pain. 

When the case returns, Avhich should be in about two or three 
weeks, the canals should be cleansed and filled with a paste made 
from campho-phenique and iodoform and cavity filled with a 
plastic filling. 

Treatment of Abscessed Deciduous Teeth. Such teeth should be 
allowed or assisted to point externally, as they will generally have 
progressed almost to the stage of pointing before the dentist is 
\isited. 

As soon as the active stage has subsided, the case should be 
given the above treatment for putrescence and filled. If abscess 
persists, as Avill occasionally be the case in spite of all methods, a 
small hole should be bored in the buccal surface just sub-gingivally 
to the pulp chamber, leaving the filling in place. 

Inter-Proximal Grinding is of service when filling is out of the 
question. This is practiced much after the same method it was 
used in primitive daj^s with the permanent teeth. 

The proximal surfaces are cut away so that they are non-reten- 
tive to food particles and the sides of the remaining surfaces thor- 
oughly exposed to the excursions of food in mastication. With 
anterior teeth the contact point is thereby moved to near the 
gingival line. With posterior teeth the contact point is removed 
as far to the buccal as possible by widening the lingual embrasure 
at the expense of both proximating teeth. This method is un- 
sightlv in the anterior teeth and not altogether without its objec- 



232 OPERATIVE DENTISTRY 

tioiis when used on posterior teeth, but it is nevertheless good prac- 
tice in many cases as it materially retards the process of decay. 

The Management of Permanent Teeth in Childhood constitutes 
one of the greatest trials of dental practice and is at the same time 
of the utmost importance. These teeth are erupted at a time of 
life Avhen the oral conditions are the most favorable to decay. 
Again these teeth are expected to give their user the longest period 
of service of any of the entire set of permanent teeth. 

It Requires Extra Vigilance on the part of the dentist to prevent 
irreparable injury to the first permanent molars, as the parents are 
not usually aware that permanent teeth are present at this age 
and do not assist the dentist in detecting incipient decays. More 
is expected and required of the first permanent molar than any 
other tooth. It must stand the onslaught of the most imhygienic 
conditions. 

It must give its possessor longer years of service and that in a 
position in the mouth most often subjected to the stress of masti- 
cation. Slight faults in enamel should be sought out early and 
filled with amalgam to be changed for gold in more mature years. 
When badly broken down they should be restored to full contour 
v/ith amalgam and croAvned only when the second permanent mo- 
lar is fully in position. If gold is used, it should be in the form of 
the inlay under about fourteen years of age as the tooth should 
not receive severe and prolonged condensing force till certain of 
full development, which is from ten to fourteen years with the 
first permanent molar. 

Treating First Permanent Molars. In treating and filling the 
root canals of these teeth before fully developed, the apical 
foramen will many times be found quite large. In some cases the 
circulation is so great that devitalization is most difficult. In un- 
certain cases it is well to use a medicated root canal filling that is 
easy of removal and instruct patient to return in a few months or 
perhaps a year for final filling. 

A Good Root Filling for Such Cases is phenolized iodoform for 
the canals, topped with gutta-percha base plate for the pulp cham- 
ber and covered with amalgam. When the case returns it will 
generally be possible to determine the length of the root and size 
of the foramen Avhen a correct root filling of chlora-percha will be 
X)ossible. In applying arsenic for devitalization in teeth that have 
not fully developed as may be expected from their age, great can 
should he exercised, as there is great danger of apical arsenical 
poisoning which nearly always causes the speedy loss of the tooth. 



CHAPTER XXXIX. 
EXTRACTION OF PERMANENT TEETH 

General Consideration. Under normal conditions tooth extrac- 
tion is not a difficult operation. However, there is no oral surgeon 
even of experience who meets with universal success. There are 
abnormal conditions which render unsuccessful any attempts at 
removal by ordinary means; but if the patient is placed under an 
anesthetic there are instruments manufactured and competent and 
able surgeons to handle them, that can remove the tooth entirely, 
and if need be the entire maxilla with it. Yet there is a limit to 
all operations. 

There is a time to stop. All oral surgeons have had the same ex- 
perience, finding cases where the unavoidable injury to the tissues 
in removing the tooth would do more harm than allowing a small 
part of the tooth to remain. To the laity, however, the skillful ex- 
traction of a tooth seems ^' quite a trick." For instance, the black- 
smith or a man of great strength, who has not made a careful study 
of the teeth and their environment, may attempt to extract the 
tooth and fail. One who has made the subject a study, although 
possessed of far less strength, removes the same tooth skillfully 
and seemingly without the exertion of much muscular effort. Un- 
less the force is properly and scientifically applied, it accomplishes 
nothing but injury. If the force is applied in a proper direction, 
with proper movements, the dislocation of a tooth is quite an easy 
matter. The old saying that there is no rule without an exception, 
and that the exception proves the rule, will apply to the rules for 
extraction; for there is probably as much difference in the forma- 
tion of teeth and adjacent structure as in the facial expression of 
different persons. Therefore it is difficult to formulate any rules 
which w^e can follow literally in all cases. Still the extraction of 
teeth is best accomplished by the application of scientific principles. 

These principles properly applied Avill give better results than 
extracting the teeth merely to get them out. For this reason we 
must study that which we wish to accomplish and how best to ac- 
complish it, by considering the various shapes of that part of the 
teeth which cause their retention in the jaw; also the structures, 
f^trength and position of those tissues which hold the teeth in place. 

Principal Retention. The constricted portion of a tooth at its 

233 



234 OPERATIVE DENTISTRY 

neck serves to retain the tooth firmly in the alveolar process, and 
constitutes its principal retention, by the process grasping the 
tooth at this point, assisted by natural adhesion of the tissues. 

Opening Mouth of Alveolus. The alveolar process is just a lit- 
tle thicker or heavier at the neck of the tooth than just below. 
The gingival part of the alveolus, the tooth's socket, is called the 
mouth of the alveolus. This mouth once opened, which can be ac- 
complished by slight fracture at this point, the removal of a normal 
tooth is made easy. 

How Can This Best Be Accomplished? By application of force 
in the line of least resistance. This varies in different teeth, owing 
to the difference in anatomical structure, the number of roots and 
direction of eruption. 

Three Forces Are Applied in the Extraction of a Tooth: Trac- 
tion, Rotation and Pressure. 

Traction is a pulling force; rotation is a motion, given the hand 
in using a screw driver, but moving the hand first in one direction 
then in another. Pressure is the force we would apply to a tooth 
in endeavoring to push it in or out of the mouth at an angle to its 
long axis. 

Position and Movements. If the patient is of mature years and 
as is often the case possessed of as much or more strength than the 
dental surgeon, it is very essential that we consider position and 
movements and that we have so calculated these matters that the 
patient is at all times fully under the control of the operator. It 
is not well to give the patient to understand that we think this 
particular tooth is a very difficult one to extract, or that we are in 
the least timid about performing the operation. 

Securing Patient's Confidence. After it has been decided to 
extract the tooth, the more precise and deliberate the operator's 
actions, the more confidence the patient will have, hence a firm but 
gentle hand instills into the patient's mind confidence in the oper- 
ator's ability. In giving the positions of the patient and operator, 
it is assumed that the latter is right handed. If such is not the 
case, the positions would be reversed. 

Position of Patient's Head. The patient's head should be in- 
clined backward. It should be firmly fixed and absolutely under 
the control of the operator. This can be accomplished in different 
Avays in the absence of a dental chair with its head rest and other 
conveniences, in which case the operator may be compelled to re- 
sort to very primitive means. 



EXTRACTION OF PERMANENT TEETH 



235 



With All Superior Teeth the operator should stand back of the 
patient and a little to the right, placing the crown of the head 
against the chest of the operator, putting the left hand around to 
the left of patient's head with the index finger holding the lip away 




Fig. 109. — An improper position with the operator doing his work at arm's length. 

from the alveolar process and at the same time lying against the 
process, to detect at once any extensive injury which might result 
from a fracture. The middle or second finger should be placed back 
of the forceps when the tooth it on the left side; or against the 
palatine process when the tooth is on the right side. Then by 



236 



OPERATIVE DENTISTRY 




Fig. 110. — Types of superior central incisors. The hrst row shows the labial, the second row 
the lingual, the' third row the mesial, and the fourth row the distal surface. (From Winter's 
Exodontia.) 



EXTRACTION OF PERMANENT TEETH 



237 




Fig. Ill — Types of superior lateral incisors. The first row shows the labial, the secoid row 
the lingual, the third row the mesial, and the fourth row the distal surface. (From Winter's 
Fxodontia.) 



238 



OPERATIVE DENTISTRY 



pressing the patient's head firmly against the head rest, or against 
the operator's chest, if using a low chair or stool, it is entirely 
from under the control of the patient, when inclined in a backward 
position. 




Fig. 112. — Position for extracting superior 



The Position in Extracting the Lower Teeth is nearly the same, 
except that the relative position of patient should be lower. The 
general position for all inferior bicuspids and molars is the same 
as for the superior. In extracting inferior incisors and cuspids 
stand directly behind the patient, and use a straight or bayonet- 



EXTRACTION OF PERMANENT TEETH 



239 




Fig. 113. — Types of inferior central and lateral incisors. The first row shows the labial, the 
second row the lingual, the third row the mesial, and the fourth row the distal surface. (From 
Winter's Exodontia.) 



240 



OPERATm: DENTISTRY 



shaped forceps, such as are used in the extraction of superior in- 
cisors. The patient's head should be the height of the operator's 
waist line, he standing directly back of patient. 

Position of Hands. The index finger should press down the 



fc^» 




] 
j 

4 




> 


4 


^^^^^^V ^^ :.j»**«l 




1 

1 



Fig. 114. —Position for extracting lower incisors. 

loAver lip and inspect the alveolar process. The thumb should be 
l^laced on the lingual surface of the process and the three remain- 
ing fingers should grasp the chin firmly, that the lower jaw may be 
fully under control. 

Operating at Arm's Length. In no case leave your patient or 



EXTRACTION OF PERMANENT TEETH 



241 




Fig. lis. — Types of superior cuspids. The first row shows the labial, the second row the 
lingual, the third row the mesial, and the fourth row the distal surface. (From Winter's Fxo- 
-dontia.) 



242 



OPERATIVE DENTISTRY 



Step in front of him, using the hand and your forceps at arm's 
length, for with the head at liberty a sudden twitch or jerk on the 
part of patient would either destroy or misguide the force applied 
and either thw:art the effort to remove the tooth or, perhaps, by 




Fig. 116. — Position for extracting right superior cuspids. 



increasing the pressure in the Avrong direction cause permanent 
injury. (See Fig. 109.) Just as an operator is extracting the 
tooth, he is often troubled by the patient grasping the arm Avhich 
is using the forceps. This is a serious matter, especially when ex- 



EXTRACTION OF PERMANENT TEETH 



243 



tracting a lower tooth, as the line of force, which the operator 

wishes to exert is opposite to that in which the patient can exert 

great force thus resulting in diminishing the power of the former. 

Overcoming Resistance of Patient. At this point the operator is 




Fig. 117. — Position for extracting left superior cuspids. 



justified in a sharp reprimand, even bordering upon crossness, per- 
haps getting the patient to desist for a moment, when the opera- 
tion may be completed. The only precaution for guarding against 
such a turn of affairs is perhaps a suggestion that the patient hold 



244 



OPERATIVE DENTISTRY 



the hands of a friend or grasp the arm or seat of the chair, instruct- 
ing him to give a vigorous pull just as you start to extract the 
tooth. This may assist him to endure the pain which is sometimes 
unavoidable when local or general anesthetics are contraindicated. 




Fig. 118. — Mesial and distal application of forceps to a superior right cuspid when both 
adjacent teeth have been extracted in advance of the cuspid. The forceps illustrated is the 
author's No. 4. 



In Superior, Central and Lateral Incisors traction or force is ap- 
plied parallel to its long axis. Next rotation. AYhy ? Because this 
is a single-rooted tooth and the root is slightly rounded. Also, 
should any of the adhering portions of the alveolar process be in 
danger of removal, the rotary motio:"^ will loosen that portion from 
the tooth. 



EXTRACTION OF PERMANENT TEETH 245 

For example, if upon the removal of a nail from a board, part 
of the board should adhere, the twisting of the nail Avould remove 
from it the adhering wood by bringing it in contact with the great- 
er body of the board. Next conies pressure, outAvard, or labial, be- 
cause this is in the line of least resistance as the process is much 
thinner on the labial than on the lingual aspect. 

Do not alternate the motion between labial and lingual pressure, 
as any pressure lingually accomplishes nothing but increased pain, 
for before the tooth can be removed the mouth of the alveolus must 
be opened and this can only be effected by labial pressure. 

All change of force should be of a rotary nature, with a slight 
labial pressure, and sufficient traction to remove the tooth upon 
the slightest fracture, or giving of the process at the mouth of the 
alveolus. 

In Inferior, Central, and Lateral Incisors traction should be in 
a line parallel with the long axis of the tooth. No rotation is neces- 
sarj^ because these teeth have flat roots wdth their greatest trans- 
verse diameter, labio-lingual. Any twisting or attempts at rotat- 
ing these four teeth will only endanger their slender roots. Pres- 
sure is slightly labial, because this is in the line of least resistance, 
the process being thinner on the labial aspect. 

Superior Cuspids. A considerable amount of force is required 
to remove this tooth, as it is the longest tooth in the human mouth. 
It is generally most firmly seated and as a rule requires more 
force for its removal than any other. Slight rotation is required, 
especially w^hen the first bicuspid and lateral incisor are in posi- 
tion. The root of this tooth is not quite so nearly round as that 
of the central incisors, but rotation should be applied to prevent 
a fracture of the adhering process of the lateral surface. This 
rotation tends to peel or scale off any adhering process by bring- 
ing it in contact with the firmer portion not disturbed. 

Pressure must be steadily labial, as this is in the line of the least 
resistance. By ''steadily outward," Ave do not mean to grasp the 
tooth, and draw it out at right angles Avith the long axis of the 
tooth; but that in addition to the great amount of traction neces- 
sary and the slight rotation there should be a certain amount of 
labial pressure upon the process. 

There is one case Avhere this rule for the extraction of the su- 
perior cuspid may be ignored. That is when the first bicuspid and 
lateral incisor have just br.n extracted. In this case instead of 
grasping the cuspid labio-lingually, place the beaks of the forceps 



246 



OPERATIVE DENTISTRY 




Fig. 119. — ^Types of inferior cuspids. The first row shows the labial, the second row the lingual 
the third row the mesial, and the fourth row the distal surface. (From Winter's Exodontia.) 



EXTRACTION OF PERMANENT TEETH 



247 



a short distance up into the cavities of the freshly extracted teeth, 
thus grasping the tooth mesio-distally. Then give the tooth great 
traction and also rotation in one direction. This rotation should 
be so applied that the labial portion of the cuspid would be moved 




Fig. 120. — Position for extracting inferior cuspids. 



towards the median line. The reason the motion should be applied 
only in this direction can be found in the fact that frequently the 
roots of cuspid teeth turn or bend backward, as they advance up 
in the process. Using traction and rotation in this one direction 



248 



OPERATIVE DENTISTRY 




Fig. IJl. — Types of superior first and second bicuspids. First row— first four teeth, buccal 
surface of tirst bicuspids; second four teeth, buccal surface of second bicuspids. Second row — 
first four teeth, lingual surface of first bicuspids; second four teeth, lingxial surface of second 
bicuspids. Third row — first four teeth, mesial surface of first bicuspids; second four teeth, mesial 
surface of second bicuspids. Fourth row — first four teeth, distal surface of first bicuspids; second 
four teeth, distal surface of second bicuspids. (,From Winter's Exodontia.^ 



EXTRACTION OF PERMANENT TEETH 



249 



the principle is applied which removes a corkscreAv from a cork, 
right or left thread. 

Inferior Cuspids. Traction with slight rotation. Labial pres- 
sure. The rules for the extraction of inferior cuspids are quite 




Fig. 122. — Position for extracting right superior bicuspids. 



similar to those for the superior cuspids, adding only that owing 
to the curve sometimes found in its single root, it is well to direct 
the line of traction force a little backward. 

Superior Bicuspids. Principally tractions, parallel with the 



250 



OPERATR'E DENTISTRY 



long axis of the tooth. Owing to the small size of the root in both 
cases and the first bicuspid frequently having a double root, other 
forces must be sparingly used in the removal of this tooth. Minute 
rotation, could ^nly be used in second bicuspid, this being a single- 




Fig. 123. — Position for extracting left superior bicuspids. 



rooted tooth. The first bicuspid is generally possessed of two 
roots. When not sufficiently bifurcated to be classed as two dis- 
tinct roots, they are so united as to form a very flat root with the 
greatest diameter bucco-lingually. 



EXTRACTION OF PERMANENT TEETH 



251 




Fig. 124.— Types of inferior first and second bicuspids. First row — first five teeth, buccal sur- 
face of first bicuspids; second five teeth, buccal surface of second bicuspids. Second row — first five 
teeth, lingual surface of first bicuspids; second five teeth, lingual surface of second bicuspids. 
Third row — first five teeth, mesial surface of first bicuspids; second five teeth, mesial surface 
of second bicuspids. Fourth row — first five teeth, distal surface of first bicuspids; second five 
teeth, distal surface of second bicuspids. (From Winter's Exodontia.) 



252 



OPERATIVE DENTISTRY 



Pressure, which is outward as this is in the line of least resist- 
ance owing to the thinness of process on buccal aspect, must be 
sparingly used; not so much because you would endanger the 
process by great force in this direction, for it is considerably thick- 




Fig. 125. — Position for extracting right inferior bicuspids. 



er over the bicuspid than over the cuspid roots, but because there 
is danger of breaking the root just below the mouth of the alveolus, 
or close to where the roots begin their bifurcation. With the sec- 
ond superior bicuspid the pressure outward mav be srreater, bear- 



EXTRACTION OF PERMANENT TEETH 



253 



ing in mind that the roots of these teeth are disproportionally long 
compared with their circumference at the neck. 

Inferior Bicuspids. Principally traction. In applying this force 
bear in mind that the line of the greatest length of these teeth is 




Fig. 126. — Position for extracting left inferior bicuspids. 



normally inclined backward instead of being in all cases at a right 
angle to the plane of occlusion. Therefore, the traction must be 
applied in a direction which would move the tooth, if it suddenly 
came loose, towards the first molar or back of where it normally 



254 



OPERATIVE DENTISTRY 




Fig. 127. — Types of superior first and second molars. The first row shows the buccal, the 
second row the lingual, the third row the mesial, and the fourth row the distal surface. (.From 
Winter's Exodontia.) 



EXTRACTION OF PERMANENT TEETH 



255 



occludes. Minute rotation is necessary for the reason that these 
are also slender-rooted teeth and quite frequently somewhat 
curved. As a rule these teeth are possessed of but one root. The 
pressure should be minutely buccal, for this is in the line of least 




Fig. 128. — Position for extracting first and second right superior molars. 



resistance. Care should be taken not to injure the upper teeth 
when inferior bicuspids and first molars leave their sockets sud- 
denly, as they sometimes do. Injury to the other teeth through 
striking them with the forceps is more likely to occur in extracting 



256 



OPERATIVE DENTISTRY 



bicuspids, as the force of traction should be applied in a direction 
which would bring them in contact with the upper teeth. 

Superior First and Second Molars. These teeth are grouped to- 
gether, as iu' the case of the bicuspids, on account of similarity in 




Fig. 129. — Position for extracting hrst and second left superior molars. 

form, position and parts surrounding them. Traction should be 
fipplied in the direction of a line drawn from the central pit of this 
tooth to the apex of the lingual root. No rotation should be ap- 
plied. Any motion in the way of rotation would not loosen the 



EXTRACTION OF PERMANENT TEETH 



257 




Fig. 130. — Types of inferior first and second molars. First row — first four teeth, buccal sur- 
face of first molars; second four teeth, buccal surface of second molars. Second row — first four 
teeth, lingual surface of first molars; second four teeth, lingual surface of second molars. Third 
row — first four teeth, mesial surface of first molars; second four teeth, mesial surface of second 
molars. Fourth row — first four teeth, distal surface of first molars; second four teeth, distal sur- 
face of second molars. (From Winter's Fxodontia.) 



258 



OPERATIVE DENTISTRY 



tooth, as one root would brace the other. It is therefore advan- 
tageous to apply the force in the line of the greatest length of one 
of these roots, the lingual. 

Pressure should be applied steadily buccally and not released 
iintil the mouth of the alveolus is opened. The process over the 




Fig. 131. — Position for extracting first and second right inferior molars. 



lingual root, which is the palatine process of the superior maxillae, 
is quite thick and heavy and seldom gives to any extent, but the 
two buccal roots are no great distance from the soft tissues and by 



EXTRACTION OF PERMANENT TEETH 



259 



this steady buccal pressure this process gives and the tooth is al- 
lowed exit. Care should be taken not to make this pressure too 
strong or apply it too suddenly, as the two roots in such close 
proximity may act as a lever and loosen a considerable portion of 
the buccal plate. 




Fig. 132. — Position for extracting first and second left inferior molars. 



Inferior First and Second Molars. Traction is necessary, the 
force of which should be applied not only upward but backward, 
remembering that the apices of the two roots are not directly un- 



260 



OPERATIVE DENTISTRY 




ttJl.Wy'^A?! 




Fig. 133. — Types of superior third molars. The first row shows the buccal, the second row 
the lingual, the third row the mesial, and the fourth row the distal surface. (From Winter's Exo- 
dontia.) 



EXTRACTION OF PERMANENT TEETH 



261 




Fig. 134. — Types of abnormal superior third molars. The first and second rows show four- 
rooted teeth, the third row shows teeth with roots that are fused, the fourth row shows teeth 
having crowns with a single cone and only one root, and the fifth row shows teeth having roots in 
which there is great variation in form. (From Winter's Exodontia.) 



262 



OPERATIVE DENTISTRY 



der the crown but posterior to it, giving the root a curve backward. 
A common error is made when the force of traction is applied at a 
right angle to the plane of occlusion. There should be no rotation. 
For as these arre double-rooted teeth rotation accomplishes nothing 
except to increase the pain by alternately increasing and releasing 
the pressure upon the highly vascular and sensitive peridental 
membrane. Pressure should be directly buccal. Although it may 
seem to the operator that the process is thinner upon the lingual 
aspect of the inferior maxillas, this is generally not the case. Yet, 
as with all lower teeth, a malocclusion or an irregularity may make 
the process thicker on the buccal surface. 

Superior Third Molars. Rotation is applied in but one direction, 
one that would roll the top of the hand towards the median line. 
Pressure should be buccal and at the same time distal. Beinor the 




Fig. 135.- — One of the many abnormal conditions found when extracting upper second and 
third molars. In this case the first molar was the only one which had erupted. The patient 
was about forty years of age. A very severe abscess appeared beneath the tissues overlying 
the second and third molars. An incision revealed the condition. The photograph shows the 
result of extracting, all three coming out attached. 



last tooth in the mouth and seated at the angle of the jaw, it is not 
very firmly supported b}' the process, which in some cases is almost 
entirely wanting on the posterior buccal corner. 

Inferior Third Molars. Traction should not be only upward, 
but backward, which can be accomplished after grasping the tooth 
with the beaks of the forceps, and allowing the handle to lie across 
and near the anterior, inferior teeth. As the traction is applied the 
handles are raised and have an amount of spring which will tilt the 
crown backwards in proportion to the distance the anterior teeth are 
separated by the opening of the mouth. Here we have the only 
tooth in which there is an almost universal exception to the direction 
in which the pressure should be applied to be in the line of the 
least resistance. In the case of the third inferior molar, it is to the 
lingual. The coronoid process of the inferior maxillae comes down 



EXTRACTION OF PERMANENT TEETH 



263 



ending in the external oblique line which is an eminence and ma- 
terially thickens the jawbone just buccal to the third molars. 

It must also be remembered that there is little of the alveolar 
process formed around the third molar, seldom more than that por- 




Fig. 136. — Position for extracting right upper third molars. 



tion which builds in around the neck to insure its retention. There- 
fore w^hen the tooth is broken off it at once becomes a very difficult 
task to remove the remaining portion, owing to the strength and 
width of the bone at this point. 

Care Should Be Taken Not to Employ Great Pressure Lingually 



II 



264 



OPERATIVE DENTISTRY 



as the anatomical structure at this point favors fracture which most 
frequently extends down and back to include the inferior dental 
foramen connected with the mylohyoid groove. 




Fig. 137. — Position for extracting upper left third molars. Note the hand grasp on the 
forceps. This grasp can also be used, sometimes, on the first and second molars. The grasp 
is a powerful one as the bones and muscles of the arm and body are in a position to exert a 
great amount of force while giving the tooth buccal pressure and rotation with the top ot the 
forceps moving toward the median line in the rotary motion and the handles of the forceps, 
are pushed out and back. While this may look awkward in the photograph many of my 
students who have tried it have been very much pleased with the results. 



Injury in this way at this particular point may be far-reaching^ 
in its effect, as fractures are most likely to follow weakened portions 



EXTRACTION OF PERMANENT TEETH 



265 




Fig. 138. — Types of inferior third molars. The first row shows the buccal, the second row 
the lingual, the third row the mesial, and the fourth row the distal surface. The fifth row shows 
incomplete and malformed molar roots. (From Winter's Fxodontia.) 



266 OPERATR-E DENTISTRY 




Fig. 139. — Elevator beaked forceps for extracting third molars. 



Ill 




Fig. 140. — Position for extracting right inferior third molars. 



EXTRACTION OF PERMANENT TEETH 



267 



of the bone, and in this case thej^ overlie the inferior dental nerve 
and vessels. 

Hemorrhage Following" Extraction. Excessive hemorrhage fre- 
quently follows tooth extraction, and is more frequently met with in 
cases after extracting first or second lower molars. 




Fig. 141. — Position for extracting left inferior third molars. 

In Mild Oases a tampon of cotton saturated with hydrogen di- 
oxide or adrenalin chloride crowded well to the bottom of the alveolus 
from which the hemorrhage is coming will usually be sufficient. 

In Severe Cases a tampon made of the scrapings of oak-tanned 



268 OPERATIVE DENTISTRY 

sole leather will prove effective. The scrapings are made by the den- 
tist from a piece of sole leather by scraping shreds from the edge. 
These should be previously prepared and ready for an emergency. 
They should be ^placed in a large-mouthed bottle and sterilized by 
dry heat and securely corked. 

Method of Applying. AVhen case presents, there should be three 
pellets made, small, medium and large about the size of the al- 
veolus. These should be introduced quickly one after the other and 
pressed to position and held there for some minutes with the ball 
of the finger. 

The leather scrapings will swell and effectually plug the alveolus. 
Also the tannin in the leather liberates the fibrinogen and an im- 
pervious clot is formed. Within twenty-four hours the last applied 
pellet of scrapings will have been raised out of the socket and the 
next two will soon follow. 

This is recommended as a method that has never failed in a long 
list of desperate cases but should not be resorted to except as an ex- 
treme measure as great soreness frequently follows the treatment 
due to the interference w^ith the circulation for some considerable 
distance about the bleeding alveolus. 

Hypodermic Injections of Adrenalin Chloride for hemorrhage 
following extraction is good practice. Load the syringe part full 
with Ringer's solution to Avhich has been added five drops of ad- 
renalin chloride. Introduce the needle, which should be long and 
large, into the apical space and inject a few drops. Repeat two or 
three times if necessary. 

Capillary Hemorrhage. If the hemorrhage is capillary, inject 
into the tissues from which the blood is cominof. 



CHAPTER XL. 
EXTRACTION OF TEMPORARY TEETH. 

The extraction of temporary teeth at the proper time and under 
normal conditions is not a difficult operation, owing to the amount 
of physiological resorption of both alveolar process and roots of the 
teeth. 

The Most Important Thing Connected With Their Extraction is 
an accurate knowledge of the order in which nature proposes to re- 
place them with the permanent set. 

Results From a Disregard of This Order. The premature or 
tardy extraction of temporary teeth has more to do with irregular 
and unsightly permanent teeth than any other one cause. There- 
fore it is well to make a careful study of the order in which the tem- 
porary set is replaced. 

Time of Eruption of the First Permanent Molar. The first molar 
teeth make their appearance at between five and six years of age. 

They are generally supposed by the laity to be deciduous and are 
frequently allowed to decay beyond remedy before the mistake is 
discovered. They are then extracted without much thought, either 
through necessity or from being mistaken for temporary teeth by 
the physician on account of the youth of the patient. The parents 
are wonderfully surprised to find such enormous roots on what they 
believe to be a temporary tooth. 

Duty of Dentist in This Matter. The practitioner of dentistry 
has a very important duty to perform in insisting upon the reten- 
tion of this tooth ; for through its loss a decided derangement of the 
permanent set results and lack of proper development of the jaw is 
encouraged. 

First Permanent Tooth to Erupt. Fig. 142 is a side view of 
child's jaw at about the sixth year. No. 1 in the top row is the 
first molar, and is a part of the permanent set, the second and third 
molars coming in after the temporary set has been entirely replaced 
by permanent teeth. 

Reasons for a Permanent Tooth at This Time. Nature in giving 
us this permanent tooth at this particular time and located at this 
particular place, seems to desire to put in a permanent fixture as 
a dividing line in the jaw between the teeth which are to be replaced, 
and those which are not, as shown by line A- A. 

Evil Effects of Early Extraction. // by Proper Extraction and 

269 



270 



operatist: dentistry 



Coacliing Into Place of the various teeth in their proper order the 
position of this line A-A, which bisects the jaw just at the mesial 
of the first permanent molar, is not allowed to move anteriorly, there 
is left just the proper space which the permanent teeth will occupy 
when they replace the temporary set, provided the jaw development 
is not interfered with, but if by the premature extraction of the sec- 
ond temporary molar, this first permanent molar is allowed to tip 
forward, thereby moving line A-A anteriorly, we have encroached 
just that much upon the space required by the permanent teeth. 

Tlie Irregularity Resulting From Siicli a Mistake will probably be 
shown in the cuspid as this is the last of the temporary set to be 



3-3-6-4-5 / 1 







t-3-5^-4—5 



Fig. 142. — Represents the complete set of deciduous teeth with the first permanent molar 
added. Lower row of figures represents the order the deciduou steeth generally erutp. 
Upper row of figures represents the order of the replacement by the permanent set. 



replaced. (See Fig. 1-43.) Again, if the first permanent molar is 
extracted before the temporary teeth have been replaced, nature 
seems to realize that further development of the jaw on this side is 
not necessary, and the jaw — ^be it lower or upper — will generally lack 
in length to correspond with its antagonist, the width of the tooth 
extracted. This may not be noticed in the exhibition of faulty oc- 
clusion or irregularities but a careful study of the features will 
show lack of artistic contour. 

Let us here consider the order in icliicli the temporary teetli arc 
replaced by the permanent set. By reference to Fig. 1-1:2. you will 
see that the order differs somewhat. 



EXTRACTION OF TEMPORARY TEETH 



271 



The lower figures represent the order of eruption of the temporary 
set. The upper figures represent the order of the replacement by 
the permanent set including this first permanent molar. Nature has 
wise reasons for this change in the order. 

The Inferior Teeth Generally Precede the Superior in the an- 
terior part of the mouth by a few weeks and in the posterior part 
by a few months with the exception of the third molars. The inferior 
third molars sometimes precede the superiors by years. It must also 
be borne in mind that the variance in length of time and age of erup- 
tion is shorter in the case of females than of males. 

Difference in Time as to Sex. Some females erupt their third 
molars as young as the sixteenth year, some males do not erupt them 
as late as the twenty-seventh year. They may be in part or entirely 
wanting in either male or female during life. They are sometimes 













^ 






' 




'A 





Fig. 143. — Irregularity resulting from premature extraction of the first deciduous molar. 

SO far retarded that they do not erupt until after the extraction of 
the first and second molars late in life. This sometimes gives rise to 
an idea in the patient's mind that he has at least part of a third set 
of teeth. 

Compare Orders of Eruption. A careful consideration of the 
two tables will show that in the temporary set the cuspid teeth erupt 
before the temporary molars, while these are replaced by the per- 
manent teeth in a different order. The first temporary molar is re- 
placed by the first bicuspid. Then the second temporary molar is 
replaced by the second bicuspid and next we have the cuspid tooth 
coming? into place, forming the keystone of the arch. 

The Reason for Nature's Change of This Order. At five years 
we find the full complement of temporary teeth in place, only twenty 
in number. Then nature puts in this dividing line by putting into 
place one permanent tooth, the first permanent molar, before she 



r. 



272 OPERATIVE DENTISTRY 

makes any attempt at interfering with the temporary arch already 
established. 

When this tooth is fully in place nature begins her work of re- 
placement. First come the centrals, then the laterals, and if we 
were to follow the order in which these same temporary teeth 
were erupted we would next have the cuspid, but not so, we have 
the first temporary molar lost and replaced by the first bicuspid, 
and as this temporary molar is lost, the first bicuspid has a space 
to occupy between two teeth, which should be in position to guide 
and assist it to proper place, leaving the second temporary molar 
in position to hold the first permanent molar in its correct posi- 
tion. Then nature replaces the second temporary molar with the 
second bicuspid. Note that these two temporary molars are wider 
than the permanent bicuspids taking their place, but the cuspid 
of the permanent set is wider than the temporary cuspid. 

Loss of Temporary Cuspid. As soon as the temporary molars 
have been replaced by the bicuspids, the temporary cuspids should 
be lost and replaced by the permanent cuspids, which as stated 
before, forms the keystone of the arch, and being a little wider 
Avedges the two bicuspids quickly back into position against the 
first permanent molar. Coming into position just in this order 
and at this time it is easily seen how the first permanent molar is 
kept in its proper place. At this time the question may arise as to 
how the permanent centrals and laterals find sufficient room, be- 
ing so much larger than their predecessors. This is compensated 
for by the development of the maxillae at this age. Some authors 
advance the idea that the difference in the space occupied by these 
four teeth was compensated for by the permanent bicuspids being 
smaller than the temporary molars. We cannot agree Avith this. 
For when the four incisor teeth are erupted in position in almost 
every instance the temporary cuspid retains its former and original 
place. 

Having completed the changing of the temporary teeth nature 
will add teeth to the posterior part of the jaw without any danger 
of subsequent irregularities. 

Evils Resulting From Disregarding the Order in Which the 
Temporary Teeth Are Replaced by the Permanent in Their Extrac- 
tion. For instance, if, as we are frequently requested by our 
patrons, Ave extract lateral incisors before the central incisors have 
attained nearly their proper height in the process of eruption, either 
one of the tAvo evils maA^ result. 



EXTRACTION OF TEMPORARY TEETH 273 

The central incisors in the inferior maxilla stand on either side 
of the symphysis, or where the two segments of the jawbone unite. 
In the superior maxilla the central incisors stand on either side of 
the median line in the intermaxillary bones. If the temporary 
laterals are extracted before the centrals are fulh^ erupted, should 
the jaw continue proper development, the central incisors will stand 
apart as they do not have the lateral incisors to hold them toward 
the median line. Thus when the laterals attempt to come into place, 
their space has been encroached upon and they may fail to crowd 
the centrals over to place. 

However in most cases the bones do not continue proper develop- 
ment and the space between the two temporary cuspids occupied 
by the four temporary incisors, is not sufficiently increased to ac- 
commodate the permanent incisors ; hence the crowded condition 
frequently met with. 

Therefore no lateral incisors should be extracted until the cen- 
tral incisors are quite in position. If the central incisors do not 
seem to have sufficient room, instruct the patient to put pressure 
with the tongue or fingers in the labial direction which will put 
them into proper position; but for no reason whatever should the 
laterals be extracted before the centrals have attained their proper 
height in the line of occlusion. 

Next we lose the lateral incisors. As this tooth erupts after the 
temporary lateral has been extracted, it very frequently loosens the 
temporarj^ cuspid, which by this time has had its root quite freely 
resorbed. Patients then request that the cuspid be extracted as 
the lateral has not sufficient room. Very frequently it will look 
as though this was necessary. However if we extract the cuspid 
at this point rest assured that there will not be room enough for 
the permanent cuspid, when it Avishes admittance to the arch. We 
should insist upon the retention of the cuspids and as the lateral 
crowds for room, development all through the jaw and especially at 
the median line will take place. 

In the superior jaw the intermaxillary bones materially develop 
at this age, and as the temporary cuspid is not lost until between 
the eleventh and thirteenth year the development is ample. So 
the incisor teeth (the two centrals and two laterals), have allotted 
to them the space between the temporary cuspids, as well as that 
which is made by the growth of the jaw between the time of their 
eruption and the loss of the cuspid teeth. 

Therefore the lateral, which did not seem to have space enough 
when it erupted Avill have ample space in five years as it is that 



274 OPERATIVE DENTISTRY 

long before any teeth in its immediate vicinity are disturbed. Na- 
ture then skips this cuspid tooth which is to hold the incisors in 
place, and the first temporary molar is replaced by the bicuspid 
which has ample room and needs little attention beyond the re- 
moval of its predecessor at the proper time. Just at this point the 
second temporary molar may become decayed or lost and patients 
will insist upon its extraction ; but if by any means the patient can 
be made comparatively comfortable it should not be extracted as 
its removal allows the first permanent molar to move forward 
caused by the growing and developing second permanent molar at 
this age. When the first bicuspid is fully erupted to the line of 
mastication, we are justified in removing the second temporary 
molar to give place to its successor. During the eruption of the 
first bicuspid, the cuspid will very frequently become loose and pos- 
sibly hard to retain, and the patient will again insist 'upon its re- 
moval; but it should not be extracted at this time. 

Leave the temporary cuspid in position until all of the other 
teeth have been replaced. If the order which nature has mapped 
out has been preserved, an even set of teeth will result in almost 
every instance. If the order has been interfered with in the least, 
the patient's mouth is placed in a condition where gross irregu- 
larities, faulty occlusion, and great disfigurement is almost sure to 
result. Therefore the great necessity for the preservation of na- 
ture's order in the extraction of the temporary teeth. It is the one 
thing to be looked after and adhered to and should be disregarded 
only in extreme cases, which does not mean merely the satisfaction 
of the ideas of parents. The operation of extracting temporary 
teeth is simple. If we have carefully looked the mouth over and 
decided that it is necessary to extract any tooth, it can be accom- 
plished with almost any pair of forceps. Great care should be 
taken not to take too deep a grasp upon the tooth, that the develop- 
ing permanent tooth, which is supposed to be close to its tem- 
porary predecessor, may not be injured in the removal of the tem- 
porary tooth. It is also advantageous to use a lance separating the 
gum from the tooth as the gum at or near the neck of the tooth 
frequently adheres quite strongly to the cementum. By using the 
lance, laceration of the parts is avoided. 

When there is nothing left but the separated or decayed points 
or unabsorbed portions of roots, it is best to remove them with a 
root elevator or chisel. 



CHAPTER XLI. 

LOCAL AND EEGIONAL ANESTHESLl 

Definition. Local anesthesia is that term applied to the results 
obtained when only a circumscribed part of the body is rendered 
without sensation. 




Fig. 144. — Horizontal injection, a represents place of puncturing the soft tissues. 

Divisions of Local Anesthesia are surface anesthesia, infiltration 
anesthesia, intra-alveolar anesthesia, and regional anesthesia (fre- 
quently called conductive). 



r 



276 



OPERATIVE DENTISTRY 




Fig. 145. — Perpendicular injection, a represents place of puncturing the soft tissues. 



Uses in Dentistry. Local anesthesia when rightly practiced and 
successfully used is the most practical anesthesia for exodontia, 
minor surgical operations about the mouth, as well as most of the 
delicate dental operations connected with pulps of teeth. The sue- 



LOCAL AND REGIONAL ANESTHESIA 



277 



cess of local anesthesia is based on a Avorking knowledge of the oral 
anatomy, scrupulous asepsis, fresh drugs and a correct technic in 
their use. 

Anatomy. The knowledge of anatomy should embrace a clear 
understanding of the muscular attachments, the position of the 
foramen and a knowledge of the position of the trigeminal nerve 
with its complete ramifications. 

Cocaine. For many years cocaine has been almost universally 
used by the dental profession as the principal local anesthetic. Its 




JFig. 146. — Drawing representing the positions of needles in local anesthesia. A, position 
for sub-periosteal injection for surgical anesthesia; B, intra-alveolus injection. This will re- 
sult in surgical and sometimes dental anesthesia. This injection is subject to very severe 
criticism due to the liability of the introduction of infection. C, intra-alveolar injection. This 
will result in dental anesthesia and quite frequently surgical anesthesia on the side toward 
which the injection is made. 



toxicity was not clearly understood at the beginning and thus oc- 
curred overdosing particularly^ with stale solutions. It has been 
fully demonstrated that some individuals could stand hea^T doses 
without showing systemic ill effects, while death would result in 
other cases Avhere only a small dose had been used. For these rea- 
sons the profession has been hunting a substitute. That substitute 
seems to have been found in novocain. 

Novocain is equal to cocaine in anesthesia producing power. It 



278 operatrt: dentistry 

is relatively non-toxic. It is particularly non-irritating even on 
the most delicate tissues. It is easily combined with suprarenin, 
and, so combined, does not loose its anesthesia producing power. 
Neither does it affect the action of the suprarenin. It can be 




Fig. 147. — First position in the mandibular injection. 

boiled for the purpose of completing sterilization. Novocain is a 
non-habit produ.cing drug, and, as claimed by the manufacturers, 
is derived from an entirely different source than cocaine, to which 
it is in no way related. The general effects upon the system af- 
ter it has been absorbed are scarcely perceptible. Neither the cir- 
culation nor the respiration suffers and the blood pressure is not 



LOCAL AND REGIONAL ANESTHESIA 



279 



increased. From experiments it has been found to be only one- 
seventh as toxic as cocaine. 

Doses. The best solution for dental uses is probably the two 




Fig. 148. — Second position in the mandibular injection. This position is taken for the deposit 
of the anesthesia for the lingual nerve. 

per cent solution for both the infiltration and the regional methods. 
The maximum dose of a two per cent solution is twenty-four cubic 
centimeters. Such a quantity would never be called for in any 
dental operation. 



280 OPERATIVE DENTISTRY 

Suprarenin is added to contract the capillaries and prevent ab- 
sorption and infiltration into the tissues beyond the field of opera- 
tion, thereby increasing the duration and strength of the anesthesia. 
It is also adde^ in certain cases to decrease the flow of blood. 




Fig. 149. — Third position for the mandibular injection. 

Dosage of Suprarenin. Differing from the amount of novocain 
used the suprarenin should be varied for individual cases. In fact 
it has probably been the practice of surgeons to use too strong a 
solution of suprarenin in their local injections. 

Preparing the Solution. In a dissolving cup, place a tablet of 



LOCAL AND REGIONAL ANESTHESIA 



281 



novocain and suprarenin to which add Ringer's solution Q. S. to 
make a two per cent solution of the novocain. Boil over the open 
flame for one-half minute to sterilize. 




Fig. 150. — Fourth and last position for the mandibular injection. 



Ringer's Solution is made as follows: Ringer's tablets; sodium 
chloride, 0.050 gram; calcium chloride, 0.004 gram; potassium 
chloride, 0.002 gram. Dissolve ten tablets in 100 cubic centimeters 



582 



OPERATIVE DENTISTRY 



of aqua dest. Sterilize by boiling and put in bottle double corked 
to be ready for use when needed. 

Stale solutions of novocain and suprarenin should not be used. 
It should be nlixed fresh for each operation. It should not come in 
contact with anything but the boiling cup and the sj^ringe and 
should not be left longer than necessary in either of these. 

Care of Novocain Tablets. The tablets should not be touched 
with the hands and should be kept in a bottle, rubber-stoppered. 
The solution should be as clear as water and discarded as soon as 
it shows a light pink color. 




Fig. 151. — A very clear and easy case with the needle in the best position for the 
mandibular injection. 



Surface anesthesia is anesthesia produced by topical application. 
The method is of advantage upon mucous membranes, as they ab- 
sorb the solution rapidly. The effect is generally not deep. How- 
ever, applied to the gum it is usually sufficient for fitting bands 
and crowns or the finishing of fillings at the gingival margin. A 
pellet of cotton saturated with a twenty per cent solution of novo- 
cain and packed on the floor of the nasal cavity over the incisor 
teeth will many times anesthetize the incisors of the respective side 



LOCAL AND REGIONAL ANESTHESIA 



283 



sufficient for operations upon the dentine and even for pulp extir- 
pation. 

Infiltration Anesthesia is the method whereby anesthesia is pro- 
duced by injection of the tissues about the nerve endings. The suc- 




Fig. 152. — This represents a difficult case where the lingula is almost entirely wanting and 
the needle has entered the sulcus too low and may yet be engaged in the tissues of the external 
pterygoid muscle which it must have penetrated to reach this position. 

cess of the method depends upon the thoroughness with which the 
tissues to be operated upon are infiltrated. If any nerve endings 
are missed only partial success is obtained. The infiltration 



284 



OPERATIVE DENTISTRY 



method is of advantage in the extraction of non-vital teeth, roots 
and parts of roots. It is the best method for the extraction of all 
deciduous teeth and roots. This method is used for any of the 
teeth in the maxilla, but the greatest success is with the single- 




Fig. 153. 



-The same mandible shown in Fig. 152 with the needle passed to position suflBciently 
high to be above the lingula represented by a. 



rooted teeth. With the mandible the iniiltration method is of little 
service posterior to the cuspids when vital teeth are involved. 
There are but tAvo injections to consider with the infiltration method 
in dental operations, namely, the horizontal and perpendicular. 



LOCAL AND KEGIONAL ANESTHESIA 285 

The Horizontal Injection for the bicuspids and molars excepting 
the third molar. By this method several teeth may be injected 
with only the one puncture of the tissues, thereby materially less- 
ening the liability of infection. This injection is contraindicated 
in diseased tissue. 

TJie Perpendicular Injection is applicable for all single-rooted 
teeth. The needle should generally be inserted just below the gum 
margin and the point carried lingually or buccally of the apex of 



Fig. 154. — This is a mandible which belongs to a class on which it is very hard to give a 
mandibular injection. Note that the internal oblique line is continuous up to the sigmoid 
notch. The lingula (a) is one cm. higher than normal and is only about four mm. back of 
the internal oblique line. Conditions like this possibly explain why even the most expert 
sometimes do not get results upon first attempt. 

the tooth the anesthesia of which is desired. The solution is in- 
jected without pressure and the needle does not go sub-periosteal 
as in distinction from the intra-alveolar. The quantity of solu- 
tion to inject is about one and a half cubic centimeters for the 
horizontal injection and about one cubic centimeter for the per- 
pendicular. A one-inch needle of small size is best suited for all 
infiltration work. 

Intra-alveolar Anesthesia has for its object the blocking of the 



286 



OPERATIVE DENTISTRY 



nerve before it enters the pulp of an individual tooth by injecting 
deeply into the alveolus. There are two injections in this method. 
They are the pericemental and the subperiosteal, or intraosseous. 

TJie Pericerhental Injection has been the most widely used of all 
the methods of local anesthesia up to this time, for the reason that 
it requires the minimum amount of the drugs used. This is a point 




Fig. 155. — First and ideal position for giving the mental injection, a represents the posi- 
tion of puncturing the soft tissues. With fleshy patients the syringe barrel will of necessity 
have to be more anterior. 



of great importance in the use of cocaine. However, with the ad- 
vent of novocain the method Avill be used less frequently, oAving 
to the liability of infection. The method has been useful in sur- 
gery, in extracting teeth, due to the accompanying infiltration of 
surrounding tissues. The needle should be short, say one-fourth 
of an inch, and of twenty-eight or twenty-nine gauge. 



LOCAL AND REGIONAL ANESTHESIA 



287 



TJie Suh-periosteal Injection in intra-alveolar anesthesia is of the 
greatest use in operating upon vital dentine and pulp extirpation. 
The needle should be short and stocky, twenty or twenty-two gauge. 
It is inserted beneath the periosteum and even into the alveolar 
process itself, as near as possible to the apical foramen of the 
tooth to be operated upon. Considerable force is used in both of 




Fig. 156. — Second position for giving the mental injection, showing the finger compressing 
the tissues over the needle inside of the mouth to facilitate injecting the canal. 



the intra-alveolar injections in counter distinction of all of the 
other methods of local anesthesia. 

Regional Anesthesia Conductive Anesthesia is strictly a nerve 
blocking process whereby a region of the desired extent is anes- 
thetized. The method is not new, having been practiced more or 
less since the latter eighties, but has received a great impetus, due 



288 OPERATIVE DENTISTRY 

to the production of an agent like novocain which is comparatively 
safe for general practice. Eegional anesthesia is by no means 
limited to the field of dentistry, but its use is as broad as the field 
of surgery on 'mankind, as well as that on the loAver animals. The 
surgeon has but to know his anatomy to be able to render a region 
as void of sensation as though the part had been amputated from 
the body. For instance, the arm is now operated on without pain, 
even to amputation, by surrounding the axillary nerve with a 
puddle of a two per cent solution of novocain with suprarenin, 
reached with a needle in the top of the shoulder posterior to the 
clavical and internal and anterior to the scapula. Aside from the 
completeness of the anesthesia obtained, regional anesthesia has 
to recommend it the fact that the injection is made far from the 
field of operation, which is many times undergoing pathological 
changes often due to bacterial invasion. About the face, we have 
seven separate and distinct nerve blocking operations for regional 
anesthesia. The injections are; Gasserian ganglion, Spheno-maxil- 
lary, Pterygo-mandibular, Mental, Infra-orbital, Zygomatic, and 
Posterior and Anterior palatine. 

The Gasserian and Spheno-maxillary Injections are employed for 
major surgical operations about the face and will be passed over 
by simply mentioning them, as the strictly operative dentist will 
have no need to employ them. However, the remaining five injec- 
tions are of vital interest to the general practitioner of dentistry 
and will be taken up in the order given. 

Pterygo-Mandibular Injection has for its object the blocking of 
the nerve supply to the lateral half of the mandible and the im- 
mediate overlying tissues. 

Technic of Injection. Palpate the posterior molar triangle hav- 
ing first sterilized the immediate field of puncture with campho- 
phenique. Then find the internal oblique line. Puncture the tis- 
sues over its inner edge, using a forty-five millimeter iridio-platinum 
needle, one centimeter above the plane of the inferior teeth with 
the barrel of the syringe resting on the occlusal surfaces of the 
bicuspids of the opposite side, as shown in Fig. 147. Push the 
needle point four or five millimeters into the tissues. Now swing 
the syringe to the position shoAvn in Fig. 148 for the lingual nerve. 
Again swing the syringe into the position shown in Fig. 149. Push 
the needle into the tissues, closely following the inner surface of 
ramus for a distance of about two centimeters in all (see Fig. 150). 
varying with the size and age of the patient. To follow the inner 



LOCAL AND REGIONAL ANESTHESIA 



289 




Fig. 157. — Position of needle in giving the infra-orbital injection, a represents the place 
of puncturing the soft tissues. If it is desired to accompany this injection with the perpen- 
dicular infiltration injection, the soft tissues should be punctured midwa}-- between the point 
marked a and the gingival margin of the gum. 



surface of the ramus will necessitate the swinging of the syringe 
to the median line as the needle progresses. It is very essential 
that the needle passes into the sulcus mandibularis, above the 
lingual, or else it will pass over this into the pterygoid muscle, of- 



290 OPERATIVE DENTISTRY 

ten resulting in false unilateral ankylosis, generally temporary, 
but sometimes more or less permanent and ahvays to be avoided. 
If anesthesia of only the pulps of the teeth is desired, the special 
part of the injection for the lingual nerve should be omitted, as 
there is less liability of injecting bundles of muscle fibers. In case 
injection is made for surgical purposes, as the extraction of the 
first molar and bicuspid, an infiltration injection had best be made 
buccal to the tooth or teeth to be extracted to include the descend- 
ing branch of the buccal branch of the third division of the fifth, 
which is given off just above the pterygoideus internus and ener- 
vates the soft tissues of the biscuspids and molars buccally. An- 
esthesia occurs in fifteen to twenty minutes and lasts about one 
hour, sometimes longer. If longer anesthesia is desired, the amount 
of the injection is to be increased up to four cubic centimeters. 

The first sign of anesthesia is the numbness of the side of the 
tongue if the injection for the lingual nerve has been included and 
of the lip above the mental foramen on that side. These are the 
signs of a successful injection and occur in a very short time, yet 
the deepest state of the anesthesia ma}^ not work back to the pos- 
terior molars for twenty to thirty minutes, as frequently happens 
with operations for the extraction of lower third molars. 

Mental Injection. The mental injection is made with a one or 
two centimeter needle passed as shown in Fig. 155. The operator 
should compress the mucous membrane and tissues over the 
foramen.. When the needle is felt under the finger (see Fig. 156) 
one cubic centimeter should be injected while pressing which will 
direct the solution through the foramen into the mandibular canal, 
anesthetizing the first bicuspid, cuspid and incisors of the respec- 
tive side. 

Infra-Orbital Injection. This injection is made in the same way 
as that described for the mental foramen, using the same length of 
needle and one cubic centimeter of the solution. Dental and surgi- 
cal anesthesia is obtained in the bicuspids, cuspid and incisors of 
the respective side. 

Zygomatic Injection. The long needle is inserted over the roots 
of the second superior molar progressing upward, backward and 
inward, depositing some of the solution as the needle progresses, 
until the position of the needle is as shown in Fig. 158 where the 
last of the solution is deposited, in all two cubic centimeters. This 
injection will reach the posterior superior alveolar nerve and the 
middle superior alveolar in case it is given off before the maxillary 



LOCAL AND REGIONAL ANESTHESIA 



291 




Fig. 158. 



-Final position of the needle in giving the zygomatic injection, 
place of puncturing the soft tissues. 



a represents the 



nerve enters tlie infra-orbital canal. It is many times advisable to 
add to this the horizontal infiltration injection as shown in Fig. 144 
to reach the anterior superior alveolar, the branches of which 
anastomose with the branches of the middle alveolar. This 
zj^gomatic injection especially when assisted by the horizontal in- 



292 OPERATIVE DENTISTRY 

jection will give dental and surgical anesthesia of the biscuspids 
and molars of the respective side. 

Palatine Injections. The needle is inserted above the gingival 
margin of the' mesial part of the third molar for the posterior 
palatine and passed upward and backward to the palatine process, 
injecting one-third of a cubic centimeter. For the anterior pala- 
tine the needle is inserted lingually and above the gingival margins 
of the superior central incisors and passed upward and backward 
to the anterior palatine canals, depositing one-third of a cubic 
centimeter. These injections will anesthetize the palatal part of 
the gums for surgical work, as extractions. 

In Conclusion. Always use the simplest method that will be 
successful. Do not inject pathological tissue. Avoid infection. 
Use only fresh solutions. Do not inject muscle tissue. /Use a solu- 
tion that is isotonic. Attempt regional anesthesia only after care- 
ful study and preparation. 



CHAPTER XLII. 
THE USE OF FUSED PORCELAIN IN FILLING TEETH. 

Definition. A porcelain inlay is a filling made of dental porce- 
lain and retained in position by cement. 

A Dental Porcelain is a solidified mass of silicious substances 
suspended in a flux of fused silicate. 

Composition. Dental porcelain is composed: First, of the basal 
ingredients which are refractory, as silex, kaolin, and feldspar. Sec- 
ond, fluxes used to increase the fusibility. Those in common use are 
sodium borate, or borax, (Na2B407), sodium carbonate (NagCOg), 
and potassium carbonate (KgCog). Third, metals and oxides used as 
pigments. 

Silex (SiOg) is the oxide of silicon. It is an infusible substance, 
insoluble except in hydrofluoric acid and is used to give strength to 
the porcelain. It gives it more translucent appearance. 

Kaolin [Al4(Si04)3.4H20] is the silicate of aluminum. It is added 
to the porcelain to give stability, and permits unfused porcelain to 
be molded and carved in the shaping of the contour. 

Feldspar [K20Al203(Si02)6] is the double silicate of aluminum 
and potassium. It forms over eighty per cent of the basal mass of 
porcelain and adds translucency. 

Pigments. The various shades and colors in porcelain are pro- 
duced by the addition of precipitated gold, platinum, purple of 
cassius, oxides of cobalt, titanium, iron, uranium and silver, pro- 
ducing the colors of red, yellow, blue, green, brown and gray. 

High-Fusing Porcelain. By high-fusing porcelain is meant a 
porcelain that requires five minutes or more to fuse at a tempera- 
ture exceeding the fusing point of pure gold. 

Low-Fusing Porcelain. This is a porcelain that requires less than 
five minutes to fuse at a temperature not exceeding the fusing 
point of pure gold. This division is one of creation by the manu- 
facturers and commonly accepted by the profession. However the 
distinction is only relative as porcelain has no definite fusing point, 
as any enamel or tooth foundation body may be fused on a matrix 
of pure gold if enough time is given to the fusing process. 

Effects of Fusing at Lower Temperatures and a Longer Time. 

A more homogeneous mass is produced. 

A more characteristic color is maintained. 

A less friable filling is produced. 

293 



294 OPERATIVE DENTISTRY 

A High-Fusing Porcelain May Be Made Low-Fusing by repeated 
fusing and grinding. 

In Building a Filling by Layers the first layer should be fused 
to a state of high biscuit otherwise the process of fusing the sub- 
sequent layers will over-fuse the first. 

High Biscuit Fuse. Heating the porcelain sufficient to obtain 
shrinkage, but not enough to glaze. 

Fine Grinding. The more finely porcelain is ground the lower 
the fusing point froui the same formula and the greater the shrink- 
age. 

Size of Mass. The larger the mass the greater the length of 
time required to fuse. 

Amount of Flux. The more flux a porcelain contains the great- 
er the liability to bubble, which liability increases as the tempera- 
ture is raised. 

Shrinkage in Fusing. High fusing porcelains shrink from fif- 
teen to twenty-five per cent. Low fusing porcelain shrinks from 
twenty to thirty-five per cent. 

Spheroiding. All porcelains have a great tendency to spheroid 
when over-fused. 

A Basal Body is porcelain composed of basal ingredients and the 
l.iigments. 

A Foundation Body is one composed of basal ingredients to which 
has been added a flux to increase fusibility, and has been ground 
less fine than enamel body to raise fusing point and give stability 
as to form. 

An Enamel Body is a basal body which has been more finely 
ground and to which there has been added more flux to increase 
fusibility. 

The Advantages of the Porcelain Inlay. AYhen skillfully made 
they more nearly harmonize Avith tooth structure in appearance. 
Thermal changes do not readily affect the pulp in vital cases as 
porcelain is not as good a conductor as metal. 

Margins of cavities well filled Avith porcelain are not readily at- 
tacked by caries, as cement dissolves out of the margin to a depth 
only equal to the breadth of the line exposed. Patients are relieved 
of sitting with the rubber dam in position for protracted periods. 

The Disadvantages of the Porcelain Inlay. The friability of 
porcelain restricts its use to locations remoA'ed from great stress. 
It is necessarv to omit the marginal bevel in all cavities, as the 



USE OF FUSED PORCELAIN TN FILLING TEETH 295 

edge strength of porcelain is no greater than full length enamel 
rods. 

The Cavo-surface Angle should be that which the cleavage of 
the enamel gives, or about a right angle. Its greatest disadvan- 
tage is the fact that the inlay must be set upon unclean walls as 
the whole process must be done under moist conditions; moisture 
being necessary to maintain the color of the teeth while trying to 
imitate their shade. This prevents the placing of the filling upon 
freshly cut surfaces which have not been moistened, the greatest 
enemy to all inlay fillings. 

Another disadvantage is that the retention of the porcelain de- 
pends upon the integrity of the cement, which is not wholly pro- 
tected at the margins. While porcelain inlays fit the cavity from 
a practical standpoint, the fact exists that they never exactly fill 
the cavity, the cement taking up the space resulting from the mis- 
fit, and is exposed in proportion to the amount of existing space 
at the margins. 

Indication for Porcelain Filling. Porcelain is indicated in the 
following : 

In cavities in the anterior location in the mouths of patients who 
have an appreciation for esthetic qualities of dental operations. 

In cavities of Class One when they occur in defects on labial 
surfaces. 

In cavities of Class Three when much of the labial wall is gone 
and rather strong lingual wall remains. 

In cavities of Class Four, plan three, vital teeth with rather 
thick incisal edge, not subjected to great stress in articulation. 

In cavities of Class Four, plan one, when proximating tooth is 
not in position as when the missing tooth is worn upon a plate or 
is to be subsequently replaced with a crown or bridge. 

In cavities of Class Four, plan four, in upper teeth when the 
lingual surface does not articulate. 

In gingival third (Class Five) in anterior teeth exposed to view 
when patient smiles. 

In cavities of Class Six on the six anterior teeth, when the porce- 
lain is built to a thickness of at least two millimeters, and in pulp- 
less lower molars, restoring the entire occusal surface. 

Contraindications. Porcelain is not indicated in the cavities not 
above mentioned, and in all locations subject to great stress and 
where good access form is difficult to obtain. 



CHAPTER XLIII, 
PREPARATION OF CAVITIES FOR PORCELAIN INLAYS 

The filling of teeth with porcelain demands some change in the 
usual and accepted form of cavity preparation for other materials. 

Access Form. Access form reaches its maximum in porcelain 
filling. Even greater access is required than for the gold inlay. 
Hence preliminary separation should be practiced with all proximal 
fillings, before forming the matrix, and generally mechanical 
separation is of advantage when setting the filling. 

Outline Form for Porcelain Inlays. Outlines must be extended 
to regions of sound enamel. The obtaining of full length enamel 
rods supported by sound dentine is imperative. Extending to self- 
cleansing margins is of additional advantage, yet not so impera- 
tive as with gold filling, as secondary decay is not as liable to take 
place about a porcelain filling. 

The outline should not folloAv a developmental groove nor cross 
a ridge at its extreme eminence. Sharp angles in outline should 
be avoided. Extension for prevention as applied to the embrasures 
is not as great as with metal fillings. 

Extension for Resistance to Stress at margins is more essential 
than with gold, due to the friability of porcelain margins. 

Resistance Form for Porcelain Inlays. The rules for flat seats 
for all fillings apply equally to porcelain fillings. The use of the 
step in Class Four is essential to give added resistance to the tip- 
ping strain. Margins should be extended to locations less fre- 
quented by the crushing strain. 

Retention Form for Porcelain Inlays. ]\Iaximum retention form 
is required in all directions except one, until the matrix has been 
formed and the filling made ready for setting, when retention 
should be added in the remaining direction. 

Acute line and point angles should be avoided: all angles being 
rounded angles until the matrix is formed. 

Convenience Form for Porcelain Inlays. The filling of teeth 
with porcelain requires more cutting for convenience form than 
for any other method. This fact makes such fillings contraindi- 
cated many times, due to the great loss of tooth substance neces- 
sary to properly form the matrix and introduce the filling. Pre- 
vious separation will overcome this cutting to a large extent with 
this as well as other fillings. 

296 



PREPARATION OF CAVITIES FOR PORCELAIN INLAYS 297 

Finish of Enamel Walls. All finishing of enamel walls must be 
completed before forming the matrix. The cavo-surface angle 
should be a right angle as the strength of fused porcelain is about 
equal to supported enamel margins. If a bevel angle exists it 
should be deeply buried. 

Toilet of the Cavity. This is attended to the same as v^dth other 
inlay fillings before forming the matrix. 

Another Cavity Toilet is necessary just before setting the in- 
lay. This consists in washing the cavity with chloroform to dis- 
solve any oily substances adhering to the cavity walls. This is 




Fig. 159. — Cavity preparation for a Class Two porcelain inlay, non-vital case with the 
porcelain occupying a portion of the pulp chamber. 

followed with absolute alcohol and moderately dried. Excessive 
desiccation is not required and in fact should not be practiced as 
the integrity of the cemental substance in the enamel is injured 
and liability to marginal checking increased. 

Preparation of Cavities of Class One. Defects in enamel. Porce- 
lain is indicated in cavities on the labial surfaces of the six an- 
terior, due to faulty enamel. These are shown as small orifices 
in the enamel surface, generally rounded in form, and is the result 
of imperfect development. The cavity should be not less than two 
millimeters in width at its narrowest point, as a smaller cavity 
than this hinders proper working. 



298 



OPERATIVE DENTISTRY 



Avoid the Exact Circle in outline, as this will bewilder the oper- 
ator as to the position when setting. In case the outline is so near 
a circle as to make position questionable, the axial wall should 
have a small 'rounded pit at one side to guide the operator in set- 
ting. 

The Axial Wall should, in large cavities, be the miniature of the 
tooth surface in which it occurs. The axial wall of small cavities 
should have a rounded groove cut around the entire circumference. 

The Surrounding Walls should meet the axial at an obtuse angle 
to relieve anv undercuts before the matrix is formed. When the 




1 




Fig. 160. — A Class Three cavity labial 
approach for porcelain inlay. 



Fig. 161. — A Class Three cavity labial 
approach for porcelain inlay. 



inlay is ready to set give the cavity retentive form by making the 
base line angles acute. 

Cavities in Proximal of Bicuspids and Molars. Class Two. Ex- 
perience has taught us that porcelain is not indicated in this class 
of cavities. Their location subjects the filling to extreme crushing 
strain which porcelain will not stand. The occlusal surfaces are of 
an irregular shape and made up of a great variety of forms with 
surfaces in any number of planes. This makes the right angle 
cavo-surface angle demanded in porcelain filling improbable and 
results in exposing porcelain margins of an acute angle. (Fig. 
159 may be used.) 



PREPARATION OF CAVITIES FOR PORCELAIN INLAYS 



299 



Cavities in Proximal of Incisors and Cuspids Not Involving* the 
Angle. Class Three. This class of cavity is ideal for porcelain in- 
lays and is by far the most sightly filling when properly done. 

These Cavities Should be Divided Into Two Classes in accord- 
ance with the three different lines of approach. 

First division, labial approach; second division, lingual ap- 
proach. 




Fig. 162. — A Class Three cavity lingual approach for porcelain inlay. 



Labial Approach. This approach should be decided upon when 
any considerable amount of the labial enamel is to be replaced and 
a lingual wall is possible. (Figs. 160 and 161.) 

The Gingival Wall should be extended gingivally to include all 
affected enamel. It should be flat axio-proximally and meet the 
axial wall at an angle slightly acute. It should meet the lingual 
wall at an angle slightly obtuse. 

The Axial Wall should be flat labio-lingually and be continu- 
ous from the axio-lingual line angle to the labial cavo-surface angle 
which results in the entire removal of the labial Avail. This wall 
should meet the lingual and incisal walls at an acute angle. The 
incisal lingual line angle should be slightly obtuse. This results 



300 



OPERATIVE DENTISTRY 



in a cavity retentive in all directions except to the labial whicli 
gives it ^*draw" in this direction. 

Lingual Approach. The whole general plan is reversed result- 
ing in the retention of all or a good portion of the labial wall and 
an entire absence of the lingual wall resulting in the draw being 
to the lingual. 

To Resist the Tipping Strain the lingual step may be added. 
This is done by cutting away a sufficient amount of the lingual en- 
amel resulting in two axial walls. One will face the proximal and 





Fig. 163. — A Class Four cavity incisal 
approach for porcelain inlay. 



Fig. 164. — A Class Four, plan one, inciso- 
proximal approach for porcelain inlay. 



the other the lingual. This creates a line angle where the two 
walls unite, the axio-axial line angle which should be a rounded 
angle. Just before setting the inlay the axial wall should be slight- 
ly grooved next to the surrounding walls, except in the region of 
the incisal point angle. 

Cavities in Proximal of Incisors and Cuspids Involving the Angle. 
Class Four, Plan One. This plan of angle restoration may be suc- 
cessfully accomplished with porcelain when the conditions of 
stress would permit of this plan being used with any other ma- 



PREPARATION OF CAVITIES FOR PORCELAIN INLAYS 



301 



terial. The cavity form is the same as that just described for a 
gold inlay. 

Proximal Approach May be Used in this instance under some 
conditions. The incisal approach may be used Avhen excess sepa- 
ration has been produced a little greater than the length of the in- 
cisal line angle, as well as more than the thickness of the inlay 
measuring from contact point to the greatest depth of the axial 
wall, which permits the filling entrance from the incisal. 

To Break the Cement Line on the Incisal Edge a rounded groove 




Fig. 165. — A Class Four, plan two, with double step for porcelain inlay. 

should be made from the external end of the incisal line angle to 
the incisal cavo-surface angle. 

Plan Two, Class Four, is suitable for porcelain filling provided 
the material will stand the strain at union of step and cavity 
proper. The double step is advised. (Fig. 164.) 

Plan Three, Class Four. The addition of the lingual step makes 
many angle restorations with porcelain practical, as the tipping 
strain can be well provided for by grooving in the lingual axial 
wall next to the distal or mesial wall according to whether the 
cavity is distal or mesial. The cavity should be so shaped that 
the draw is directly to the incisal. The gingival Avail should be 



302 



OPERATIVE DENTISTRY 



flat and meet both axial walls at an acute angle. The axio-labial 
line angle should be acute. The lingual axial wall should be con- 
cave. The axio-axial line angle should be a rounded angle and 
continue out to the incisal cavo-surface angle. 

Plan Four, Class Four. In angle restoration the creation of both 
incisal and lingual steps is most popular. The incisal step is formed 
in much the same way as when gold is to be used. HoAvever the 
pulpal wall should be placed farther from the incisal edge and 
be laid in a plan less acute to the axial wall than for gold. 

The angle formed by the junction of these walls, the axio-pulpal 
angle, should be rounded. In forming the lingual step the enamel 
may be removed entirely to a level of the gingival wall, or it may 
be only as much of the incisal portion as may seem necessary to 
strengthen the body of porcelain in the incisal region and resist 
the tipping strain. 




Fig. 166. — A Class Four, plan three, for porcelain inlay. 



The Double Step is of service in cases where there has been ex- 
tensive loss of tooth structure, particularly in non-vital cases. 
This plan results in a gingival Avail and Uvo pulpal Avails; also in 
tAvo short axial Avails placed on an equal number of levels. The 
gingival and pulpal Avails should be made to meet the axial Avails 
at acute angles. Each of the tAvo pulpal Avails should be grooved 
from the connecting axial Avails, and each axial Avail in the central 
portion resulting in a continuous groove from the gingivo-axial line 
angle to the incisal edge. This cavity has draAv directly to the 
incisal. 

Cavities Occurring in the Gingival Third of Class Five. Labial 
cavities in the gingival third are favorite places for porcelain and 
should to a large measure displace gold. If the cavity extends be- 
neath the gum line, the gum should be forced from position by 



PREPARATION OF CAVITIES FOR PORCELAIN INLAYS 



303 



previous packing of gutta-percha or cotton saturated with ehlora- 
percha. 

Outline Form should be the same as for other filling. The axial 
wall should be the miniature of the tooth surface wherein the 
cavity occurs. The gingival wall should be flat and meet the axial 
at an acute angle. All other surrounding w^alls should meet the 
axial at slightly obtuse angles. This gives a cavity with draw to 
the labial allowing the incisal portion to swing out in advance, 
the inlay going to place gingival first. 

This hinge movement is slight but constitutes a valuable point 




Fig. 167. — Class Five cavities for porcelain inlay. 

in subsequent retention. Just before setting the inlay the axio- 
incisal line angle should be sharpened to add retention form. In 
cases where the decay resulting in a cavity is materially JiorsesJioe 
in form the cavity may be filled by tw^o distinct operations. 

This is accomplished by filling the cavity with cement and cut- 
ting out one-half and filling with porcelain. This completed, the 
other half is cut out and the operator then proceeds to fill that por- 
tion. This results in two porcelain fillings with cement between. 

One Point Must Be Observed. The first portion of porcelain 
will necessarily slightly overlap a cement wall. Before setting, 
this portion of the inlay must be ground at the expense of the ex- 
ternal surface of the filling to reverse the draw, or this portion of 



304 



OPERATIVE DENTISTRY 



the remaining cavity will be found with an objectionable under- 
cut hard to manage. 

Restoration of a Portion of the Incisal Edge. The general out- 
line in this elass of cavities when they are simply a notch in the 
body of the tooth, is that of the half moon when viewed either from 
the labial or the lingual. However the lingual enamel should be 
removed for a greater distance root-wise resulting in a lingual 
step to provide against the tipping strain. The pulpal wall should 
have a groove mesio-distally in its central portion and extend well 




Fig. 168. — Incisal cavity for porcelain inlay. 



up along both mesial and distal walls, and with the larger cavities 
coming out to the eavo-surface angle. 

Restoration of the Entire Incisal Edge — Outline Form. The en- 
amel is chiseled root-wise till it is firm and will result in a thick- 
ness of porcelain at all points equal to at least two millimeters. 

Retention is accomplished by the addition of pins, or a generous 
lingual step, or both. 

In vital cases where pin retention is to be used there should be 
cut a V-shaped groove mesio-distally, the spreading angles of 



PREPARATION OF CAVITIES FOR PORCELAIN INLAYS 305 

which should come just short of the dento-enamel junction labially 
and lingually. Mesially and distally it should continue to the 
cavo-surface angle. A pin hole should then be bored in the ex- 
treme ends of this groove not a great distance from the dento-en- 
amel junction in the dentine to receive the pins. When the lingual 
step is to be added the enamel on the lingual is removed additional- 
ly to a distance root-wise at least equal to the labial exposure ; also 
an amount of dentine sufficient to make the newly created axial 
v/all meet the two pulpal walls at right angles. If pins are to be 
added the holes should be bored in the floor of the pulpal wall 
nearer the labial surface. 

In Pulpless Six Anterior Teeth the pulp chamber may be rounded 
out and porcelain so baked as to form a post of porcelain for re- 
tention. 




Fig. 169.— A Class Six cavity using pin anchorage for porcelain inlay. This plan is also 
used with the gold inlay. 

Pulpless Molars are treated in the same way. 

Treatment of Teeth With Malformed Enamel. The major por- 
tion or all of the enamel can be successfully replaced with porce- 
lain. 

The enamel is removed to the desired point resulting in a 
gingival wall entirely encircling the tooth. Sufficient dentine is 
removed in the incisal region to render the largest girth at the 
gingivo-axial line angle which is continuous around the tooth. This 
leaves a peg-shaped body of dentine over which the porcelain is 
telescoped. The method is termed the jacket crown and the method 
of construction and setting is fully described in the writings of 
others on crown work. 



CHAPTER XLIV. 

THE CONSTRUCTION AND PLACING OF A PORCELAIN 

INLAY 

Following the completion of cavity preparation the next step in 
porcelain inlay filling is the formation of a matrix. 

A Matrix is a thin piece of metal shaped to the cavity form in 
which the porcelain is fused. 

Matrix Material. The matrix materials in common use are pure 
gold, pure platinum and platinized gold. Pure gold and platinized 
gold can be used only with what is termed Ioav fusing bodies, 
while pure platinum can be used with either high or low fusing 
bodies. Gold is more easily shaped to cavity form, but tears more 
easily and does not hold its shape as well after burnishing. 

Thickness of Foil. The most popular thickness of platinum foil 
to be used in the construction of a matrix is 1-1,000 of an inch. 
Thicker than this is difficult to manipulate, Avhile the thinner foils 
tear too easily, and are more liable to distortion during the 
processes of building and fusing. 

Annealing of Matrix Material. This is best accomplished by 
placing the entire sheet of material as it comes from the supply 
house in the electric oven and bringing it to the desired tempera- 
ture before cutting off the piece desired for the case in hand. Pure 
gold and platinized gold should be brought to the full red heat or 
about 1,200° or 1,300° F. Platinum should be carried up as high as 
it is expected to carry the temperature during the process of fusing 
and held there for two or three minutes. It is not necessary to an- 
neal several times during the process of shaping the matrix. 

Methods of Forming the Matrix. There are three general 
methods in use for the construction of a matrix. First, burnishing 
directly into the cavity. Second, swaging over an impression of 
the cavity. Third, sAvaging into a model of the cavity. 

Each has its advantage in different cases and are recommended 
by all porcelain workers. However, the combination of the first 
and second methods will bring good results and is the method re- 
quiring the least time. 

Technic of the Combination Method. Fiist take an impression 
of the cavity. If the cavity is large it is best to use modeling com- 
pound, trimming off that part which flares out over the external 

306 



CONSTRUCTION AND PLACING OF PORCELAIN INLAY 307 

surface of the tooth. The matrix is then shaped over this impres- 
sion with the fingers, using the soft part of the ball of the thumb 
as a counter die. 

The most prominent parts of the impression will represent the 
deepest portion of the cavity and will assist in causing the matrix 
to reach this without tearing which is accomplished by using the 
impression to crowd the matrix to position. The impression 
should be removed leaving the matrix, which has been by this 
means partially swaged, in the cavity. 

The Removal of the Impression Without Carrying Away the 
Matrix is accomplished by bending the portions of matrix exposed 
above the cavo-surface angle aAvay from the impression. The 
matrix should not be burnished down onto the external surface of 
the tooth until the other portion has been made to thoroughly con- 
form to the cavity walls. 

When the impression has been removed the matrix should be 
thoroughly burnished to all cavity Avails beginning at the seat of 
the cavity first. This burnishing is done Avith suitable smooth- 
faced instruments, keeping moistened chamois skin discs between 
the instrument and the matrix. 

The cavity should now be packed with damp cotton halls crowd- 
ing the matrix ahead of them to every part of the cavity. While 
this cotton is in position, the matrix should receive thorough burn- 
ishing at the caAdty margins and finally be turned out on to the ex- 
ternal surface of the tooth a distance of one-fourth of a millimeter 
to one full millimeter in all locations except one, Avhich may be 
tAvo or three millimeters. 

This one place AAdll facilitate liandling during the process of fill- 
ing in the porcelain. The cotton may noAv be remoA^ed and gum 
camphor or gold inlay casting Avax croAvded into the cavity over 
the matrix, filling the caA^ty nearly full Avith one piece of material 
packed to place Avith a flat-faced amalgam burnisher as large as 
the caA^ty Avill admit. 

Removal of Matrix. The matrix is then removed from the cav- 
ity by sticking the tine of an explorer into the body of the cam- 
plior or icax near its central portion. The matrix and Avax or 
camphor still on the tine of the explorer should be immersed in 
alcohol if camphor has been used or chloroform if Avax has been 
used, AA^hich Avill immediateh^ loosen the tine and dissolve the ma- 
terial from the matrix, after AA'hich the matrix should be picked up 



308 OPERATI\^ DENTISTRY 

in the lock tweezers at that portion where the metal has been left 
to extend the farthest from the cavo-surface angle. 

The matrix should now be passed through the alcohol flame when 
the camphor or wax remaining will be burned off leaving no ash. 

Wood as an Impression. In simple small cavities it is well to 
shape a piece of soft pine (as cork pine) to proximately fit the cav- 
ity. This should be then introduced against the deepest portion 
of the cavity and given a few blows from the mallet which will 
cause the wood to conform to the floor of the cavity. This should 
then be used as an impression and the matrix forming proceeded 
with, as described when modeling compound has been used. The 
use of the stick with modeling compound on the end is of advan- 
tage in large deep cavities where the pulp chamber is to be filled 
with porcelain in place of metal pin. By this means it is possible 
to place a matrix well to the bottom of any cavity without tearing, 
provided the walls are regular and have the proper draw devoid of 
under cuts. 

Taking the Spring Out of a Matrix. If a matrix seems to retain 
'^ spring" and does not seem to lay w^ell on all surfaces, as fre- 
quently met with in complex cavity outlines, this may be removed 
by the following method : When cavity is thoroughly packed with 
wet cotton, stretch a piece of rubber dam over the matrix, cotton 
and all, and thoroughly burnish the entire outline. If ''spring" 
still persists, remove the matrix and anneal, and then repeat the 
method when it will be found that the fault has been removed. 

Selection of Porcelain. The selection of that portion of the in- 
lay which replaces dentine and that Avhich replaces enamel should 
be attended to before the process of building begins. The part 
replacing dentine should be of foundation body coarsely ground 
and of a yellow color in all vital cases. In devital cases this shade 
may be darkened by the addition of the brown shade, and in vital 
teeth for young patients, particularly if the cavity is shallow, or 
on a distal surface, the addition of white powder is of advantage 
to lighten the shade of yellow. 

The enamel shades may be decided upon after a careful study of 
the shades and hues found in each case. Delicate shading is se- 
cured by building one layer upon another, thus getting the benefits 
of reflected light. The deep and pronounced shades and colors are 
best obtained by building in sections. Teeth that are much of one 
color and not pronounced in lines of shades will be best represented 
by the layer method, while teeth that are decidedly yellow at the 



CONSTRUCTION AND PLACING OF PORCELAIN INLAY 309 

cervix and pronouncedly blue at the incisal edge are best repre- 
sented by building in sections provided; the cavity involves both 
regions spoken of as in Class Four (proxinio-incisal). 

After the different sections have been applied and brought to a 
hard biscuit fuse, a uniform layer of neutral color is applied over 
the whole and all fully fused. 

Applying the Porcelain to the Matrix. The foundation body is 
put upon the porcelain or glass slab and sufficient distilled water, 
or alcohol or a mixture of both, added to make a stiff paste, stiff 
enough to retain its shape when taken up on the point of a spatula. 

A small quantity of this is laid in the bottom of the matrix and 
by a little jolting made to flow over the surface. This jolting is 
best produced by drawing the edge of a fine gold file over the 
tweezers holding the matrix. The additions should be continued 
until sufficient body has been added. Excess moisture is removed 
by repeated jolting and absorbing with blotting paper. Dark col- 
ored blotting paper is used so as to detect any paper fibers which 
by accident adhere, which should be removed. The addition of 
dry porcelain of the same color will take up the excess moisture, 
the surplus adhering powder being brushed off with a small brush. 

In Case the Matrix is Torn, the opening has to be comparatively 
large to cause the porcelain to run through, unless the matrix is 
damp on the cavity side or too moist a mix is being applied. 
Should any of the porcelain flow through, it can be removed with 
a dry brush provided the porcelain has been rendered quite dry. 

Do not apply a wet brush to the cavity side of the matrix. The 
inlay should now be placed in the oven and fused sufficiently to 
produce the greater part of the shrinkage, but not to a full gloss. 
When removed from the oven if more foundation is needed it 
should be added and fired to a high biscuit. 

The Enamel in Proper Shades is now added, either in layers or 
sections, and again fired to a high biscuit. The inlay should then 
be tried into the cavity for bulk and contour. If not correct more 
enamel is added. When the contour suits, the inlay is replaced in 
the oven and fired to a full glaze. The skill necessary to reproduce 
the colors of the teeth comes with practice and the longer one en- 
gages in this work the more often will the results please the oper- 
ator. 

Technic of Fusing* Porcelain. The furnace should be first heated 
up to a bright red and held there for a minute or two, to thor- 



310 OPERATIVE DENTISTRY 

oughly warm the fire clay entirely through, and then the lever re- 
turned to the first button to maintain a vrarm oven. 

When ready to fuse, the furnace is completely shut off provided 
the oven shows any redness. Never put an inlay mix into a hot 
oven, as it causes too rapid evaporation of the moisture, producing 
checks and an extremely friable porcelain. 

When the inlay is in position in the oven the lever is put on the 
second or third button and advanced only when the needle of the 
milliamperemeter ceases to advance. The heat should be increased 
gradually and when it has reached the desired degree immediately 
shut off. Each furnace has a wa}^ peculiar to itself and each oper- 
ator should learn the time for perfect results. 

Grinding to Contour. After the final fusing the inlay should be 
tried in and ground to contour and articulation on the incisal or 
occlusal surface before removing the matrix. 

To Remove the Matrix. Drop the inlay and the matrix in alco- 
hol or water, then remove and peel the matrix from the inlay, draw- 
ing from the margins all around first, then from the body of the 
filling. This procedure prevents chipping at the margins. 

Etching the Cavity Side of Inlay. When the matrix has been 
removed the inlay should be embedded, contour surface down, into 
a sheet of pink base plate wax. With a warm spatula it is sealed 
entirely around, being sure to cover the edges of the inlay on the 
cavity side for a short distance, say one-half millimeter. This 
leaves the cavity side exposed, upon which is applied hydrofluoric 
acid. This is applied by dipping a stick in the wax bottle in which 
the acid is delivered, and painting the inlay with a small quantity 
of the acid. Two minutes will generally be sufficient to thoroughly 
etch the surface. 

Toilet of Inlay. The inlay should be flooded with water, re- 
moved from the wax and placed in boiling Avater for a few minutes 
and then given a chloroform bath, and dried with warm air while 
laying on spunk or blotting paper, and should not be again con- 
tacted with the hands on the cavity side. 

Toilet of Cavity. The cavity should be rendered dry. All in- 
lays, and particularly the large ones, are best set with white ce- 
ment with the faintest tinge of cream. The attem.pt to match the 
color of tooth substance with the cement is an error as the pigment 
in the cement increases the shadow line which is objectionable. 
Use a white cement mixed to the consistency of greatest adhesive- 
ness yet thin enough to flow from between inlay and cavity walls 



CONSTRUCTION AND PLACING OF PORCELAIN INLAY 311 

with light pressure. This will be about the consistency of thin 
cream. The cement should be thoroughly and rapidly spatulated 
and when the ''stick" is felt under the spatula it should be ap- 
plied to the cavity and the surface of the inlay which is immediate- 
ly placed. Use a non-corrosive spatula, preferably bone or agate. 
Apply to the cavity with a flattened orangewood stick. Press in- 
lay to position with a stick of orangewood using gentle pressure, 
gently tapping the end of stick with the knuckle of the forefinger, 
or blows of equally cushioned nature. 

In labial and buccal fillings (Class Five) the inlay should re- 
ceive gentle pressure for five or ten minutes. In proximal (Classes 
Three and Four) the filling should be gently wedged against the 
proximating tooth or tightly ligatured to position and so left for 
some hours. 

The Finishing' should be left till another sitting. If the building 
has been well done there will be little to do. All overhanging mar- 
gins should be dressed down with fine stones and disks and the 
surface polished with small Arkansas stones, using a light hand 
and keeping the stones well watered. 



APPENDIX 

As a suggestion to those who use this book as a text in college 
teaching, the author submits the foUoAving courses based on the 
subject matter of the foregoing chapters and illustrations. Herein 
are also shown the author's selection of instruments for doing the 
work and Dr. Rathbun's ''dentech" to take the place of the pa- 
tients. 

While carrying out this course the freshman completes the first 
seventeen chapters. During the second year the student hurriedly 
reviews the first seventeen chapters and completes the remainder of 
the book. The courses in both the first and second years are quiz 
courses. The third year students review the book entirely with 
the teacher giving lectures elaborating on each subject by adding 
personal ideas to give individuality to the course. The fourth 
year is devoted to a study of the subject as presented by other writ- 
ers, each member of the class writing papers for the consideration 
of his fellow-classmen, who should be allowed to discuss the papers 
presented. 

Operative and Dental Anatomy Technic Courses 

FRESHMAN YEAR. 

First Semester. 

(1) Fourteen plaster tooth carvings, three times Black's measure- 
ments. 

Second Semester. 

(2) Fourteen bone tooth carvings, average measurements. 

(3) Six bone tooth carvings from models of extracted teeth. 

(4) Nine cavities as assigned in technic block, finished March 1st. 

(5) Twenty-four cavities as assigned in fourteen plaster teeth, 
finished May 1st. (See Figs. 13 and 14.) 

JUNIOR YEAR. 

First Semester. 

(6) Fill nine cavities in technic block. 

(7) Mount bone carvings and natural teeth on ''dentech." (See 
Fig. 177.) 

(8) Fill natural teeth as per following list. 

A. Second lower molar. Occlusal. Class One cavity. Expose 

313 



314 



OPERATIVE DENTISTRY 




Fig. 170. — Excavators, group one. Chisels for securing outline terra. 



APPENDIX 



315 




t 



Fig. 171. — Excavators, group two. Spoons for removing softened dentine. 



316 



OPERATR^ DENTISTRY 



Fig 172 -Excavators, group three. Enamel hatchets for completing outline form and 
i ig. ±/-. -. flot*o«inCT ripntine walls. 



flattening dentine walls, 



APPENDIX 



317 




Fig. 173. — Excavators, group four. Instruments for cutting point angles and sharpening 

base line angles. 



318 



OPERATIVE DENTISTRY 





Fig. 174. — Excavators, group five. Hatchets and hoes for cutting ascending line angles and 

completing retention form. 



APPENDIX 



319 




Fig. 175. — Excavators, group six. Gingival marginal trimmers. Instruments for shaping and 

finishing gingival walls. 




OPERATIVE DENTISTRY 





Figs. 176. A and B. — Gold building pluggers. 
Numbers one to seven inclusive are for building 
foil gold. These instrumenfls have the same sized 
serrations and are made in conformity with the 
principles taught in Chapters XIX and XX. In- 
struments numbers eight to twelve inclusive are 
for building fiber gold. These five instruments 
have serrations specially adapted for use on this 
form of gold. In changing from foil builders to 
fiber gold builders or vice versa the surface of 
the gold should be gone entirely over, before add- 
ing the differently prepared gold, with the instru- 
ment with which the operator expects to condense 
the new gold. 



Fig. 
176-^. 



:s.sj^s^?«:- ;• 



APPENDIX 



321 




Fig. 177. — Dr. Rathbun's dentech with teeth in position ready for practice work. This 
appliance may be used either on the bench or head rest of any operating chair. The author 
advises the advanced work with this on the dental chair to familiarize the student with 
positions. 



322 



operatrt: dentistry 



pulp. Devitalize. Remove pulp. Fill pulp canals. Fill cavity with 
silver cast inlay. 

B. Upper lateral. Lingual pit. Class One. Open and treat for 
putrescence. Fill pulp canal. Fill cavity with amalgam. 

C. Second lower bicuspid. Occlusal pit. Class One cavity. Open 




Fig. 178. — This shows a student who has kept his appointment with his patient. "Mr. 
Dentech." The student is required to keep an appointment book with this dummy patient 
the same as though the mouth to be worked on was animate. 



and treat for putrescence. Fill pulp canal. Fill cavity with tin. 

D. Upper central. Distal. Class Three cavity. Expose pulp. 
Devitalize. Fill pulp canal. Fill cavity with cement. 

E. First lower molar. Mesial. Class Two cavity. Devitalize. 
Eemove pulp. Fill pulp canal. Fill cavity with tin, restoring con- 
tact. 

F. First superior molar. Mesial. Class Two cavity. Devitalize. 
Fill pulp canals. Fill with amalgam restoring the contour and con- 
tact. 



APPENDIX 



323 



G. Second superior molar. Class One cavity. Central pit rather 
large. Prepare so as not to injure the pulp in vital case. Fill with 
amalgam. 

H. First and second superior bicuspids. Mesial cavities. Class 




Fig. 179. — Forceps made after the patterns of the author. The middle and right hand 
pairs are spoon beak forceps, hollow ground and should be kept reasonably sharp by grinding. 



Two. Expose pulps. Use pressure anesthesia. Remove pulps. Fill 
pulp canals of both. Fill both cavities with tin. 

/. First inferior molar. Class Five. Prepare cavity and fill with 
amalgam without injury to the pulp. 

J. Admitted to infirmary practice. 



324 OPERATI^'E DENTISTRY 

Second Semester. 

(9) Twenty-four cavities in carved bone teeth mounted on ''den- 
tech," duplicating those in plaster teeth of the freshman year. Cut 
and fill in the order listed, completing each filling before cutting the 
next cavity. 




Fig. ISO. — Forceps made after the patterns of the author. The right hand pair is a combination 
of cow horn and hawk bill beak. 



INDEX 



Abrasion; 

causes not clear, 96 
incisal; 97 
mechanical^ 195 
Abscess: 

alveolar, acute, 179 
alveolar, chronic, 224 
Absorbents, 187, 194 
Absorbent cotton, use of, 175 
Access form, defined, 31 
importance of, 31 
surgical for, 31 
Access form for: 
class two, 

first method, 58 
second method, 59 
third method, 59 
class three, 72 
inlays, 99 

class two, 102 
class three, 105 
silicate, 150 
Affected dentine, 29 
Alloy, 

ageing of, 140 
annealing of, 141 
Alveolus, opening mouth of, 234 
Amalgam : 

cavity preparation for, 141 

contraction of, 140 

cutting from the margins for, 144 

defined, 139 

edge strength of, 140 

expansion of, 140 

expressing mercury from, 143 

flat seats for, 141 

flow of, 140 

history, 139 

making the filling, 144 

making the mix, 142 

matrix, removal of, 114 

matrix, use of, 141 

maximum strength of, 140 



Amalgam — Cont 'd 
objections to, 139 
polishing of, 145 
properties of, 139 
proportion of alloy and mercury, 

142 
reception of, 129 
trimming the filling of, 144 
Anesthesia: 

conductive, 285 

infiltration, 282 

intra-alveolar, 201 

local and regional, 275, 292 

pressure, for pulp, 213, 214 

pulp, 212 

sensitive dentine, 202 

sensitive dentine, general for, 

202 
surface, 282 
Angles, avoided in outline, 34 
avoided in outline, class two, 61 
line, class two, 62 
Angle restoration: 

conditions demanding, class four, 

78 
plans of, class four, 78 
plan one, class four, 85 
plan two, class four, 87 

indications for, 88 
plan three, class four, 89 

indications for, 88 
plan four, class four, 90 
Appendix, 313, 324 
Arsenic tri oxide: 

caution in use of, 217 
combination, 215 
poisoning from, 217 
retainer, 216, 217, 
technic in, use of, 216 

amalgam as a, 216 

cement as a, 217 

cotton as a, 217 

stopping as a, 217 
soreness from, 217 
time of application of, 217 



325 



326 



INDEX 



B 

Bevel angle^ base of, 28 

defined, 27 , 
Broach, cotton carrying, 226 
BurnisMng cohesive gold, 137 



Calculus ; 
salivary: 

composition of, 181 

removal of, 183 
serumal: 

appearance of, 183 

deposited, 182 

distinguished from, 184 

removal of, 184 
Canal point, size of, 227 
Canal, filling, pulp: 
chlora-percha as, 227 
general, 225-228 
gutta-percha as, 227 
immediate, 215, 218 
material for, 225 
most popular, 227 
necessity of, 225 
objective point in, 225 
perfect, 225 
ready for, 225 
Caries : 

progressive stage of, 207 
rapid, indications of, 167, 195 
Carious dentine: 
in large decays, 44 
in large proximal cavities, 44 
predisposing causes, class one, 48 

class two, 58 
removal of remaining, defined, 
44 
Cavities: 

axial surface, 21 

base of, 24 

buccal and lingual surfaces, 55 

cavo-surface angle, defined, 27 

for fused porcelain, 295 
class one, defined, 22 
class two, defined, 22 

early detection essential, 58 
non- vital, 67 



Cavities — Cont 'd 

class three, defined, 22 

form of, 72 

management of, 72 
class four, 78-92 

defined, 22 

inlay, 63 
class five, 93-95 

defined, 22 

prevention of, 93 

tendency to spread, 93 
class six, 96, 97 

cause of, 96 

defined, 96 

early restoration in, 97 

line angles in, 25 

occlusal surfaces, 97 
complex, 21 

distal superior cuspids, 91 
divisions as to manipulation, 22 
groups of, 21 
how named, 21 
increased outline in, dangers of, 

37 
laying of outline, 37 
mesio-disto-occlusal, non-vital, 

68 
mesio-disto-occlusal, vital, 6S 
point angles in, 25 
proximal, 21 
simple, 21 

stress from within, 38 
toilet of, 45-47 
Cavity nomenclature, 21-28 
necessity of, 21 
names, how derived, 21 
Cavity preparation: 
completed, defined, 29 
general consideration of, 30 
gold inlay, 98-111 
modification of form, 29 
order of procedure in, 29 
porcelain inlay, 296-305 
Cements: 

amalgam, and, 170 
cavity preparation for, 146 
cement, int. v. defined, 148 
cement, n. defined, 148 
cement, t. v. defined, 14S 



INDEX 



327 



Cements — Cont 'd 

cementation, n. deimed, 148 
gold, and, 169 
porcelain, and, 171 
retainer of arsenic, 217 
varieties of, 146 
Cementum, exposure of, 196 
Children's teeth, management of, 
229-233 
cavities, class one, in, 230 
cavities, class two, in, 230 
cavities, class three, in, 231 
cavity preparation in, 230 
early attention imperative, 229 
exposed pulp, in, 231 
extension for prevention in, 230 
extension for resistance in, 230 
tilling materials in, 230 
first difficulty in, 229 
first visit of child, 229 
inter-proximal grinding in, 231 
root filling in, 232 
Chip blower, use of, 176 
Chloroform, 202 
Clamp : 

cervical, use of, 194 
methods of applying, 191, 194 
Cocaine: 

for sensitive dentine, 277 
local anesthesia, with, 277 
Combination fillings, 

cement and amalgam, 170 

cement and porcelain, 171 

defined, 169 

gold and cement, 170 

gold, cohesive and non-cohesive. 

170 
gold and platinum, 170 
gold and tin, 169 
object of, 169 
silicate and amalgam, 172 
silicate cement and fused por- 
celain, 171 
silicate and gold, 171 
Contact point, proper, 32 
build of, amalgam, 144 
class six, 97 
condensing of, 132 
position of, 132 



Convenience form, 42-43 
abuse of, 42 
class one, 50 
class two, 63, 66 
class three, 77 
defined, 42 

distal superior cuspid, 92 
inlays, 99 

maximum required, 42 
minimum required, 42 
porcelain inlays, 296 
previous separation lessening, 42 
silicate, 154 
sparingly used, 42 
suitable instruments for, 42 



Dentech, 321 
Deposits, 180 

food ias related to, 181 

habits as to, 181 

kinds, upon the teeth, 180 

mouths most subject to, 181 

salivary, prevention of, 182 

time of, 181 
Disinfection and pulp protection, 

46 
Disks and strips, are in use of, 

46 
Dryness, 187 

importance of, 187 

neglect of, 187 



Electric lamps, use of, 176 
Enamel : 

defined, 97 

edge, 97 

malformed, 305 

margin, 2 7 

plane of, 45 
Enamel walls, 45 

axial, surface pit, 56 

class one, 50 

class two, 63, 67 

class three, 77 

inlay, class two, 104 

inlay, class four, 109 



328 



INDEX 



Enamel walls — Cont'd 
inlay, porcelain, 297 
silicate, 154 
Examination of mouths: 
care in, 175 

instrunients needed in, 175 
light hand in, 174 
when completed, 176 
Exclusion of moisture, 186 
as a time saver, 189 
better view of the cavity, 188 
decalcification detected, 189 
for proper canal treatment, 188 
for sterilization, 188 
methods of, 186 
pain decreased by, 189 
Explorer, use of, 175 
External enamel line, defined, 27 
Extensions gingivally: 
buccal, class one, 56 
buccal, class two, 60 
Extension for prevention: 
approaching the gum, 56 
buccal pits, 56 
defined, 35 
esthetic reasons, 74 
Extraction of teeth, permanent, 
233-268 
care in, 263 
forces used in, 234 
general consideration of, 233 
hemorrhage following, 267, 268 
movements in, 234 
positions in, 234 
position of arms in, 240 
position of hands in 240 
position of operator for inferior, 

238 
position of operator for superior, 

235 
resistance of patient in, 243 
rules for, 

inferior bicuspids, 253 
superior bicuspids, 249 
inferior cuspids, 249 
superior cuspids, 245 
inferior incisors, 245 
superior incisors, 244 
inferior molars, 259 
sui^erior molars, 256 



Extraction of teeth: 
rules for — Cont'd. 

third, inferior molar, 262 
third, superior molar, 262 
temporary teeth, 269-274 

early extraction, evil results of, 

269 
first molar, related to, 269 
first molar, time of eruption, 
reasons for, 269 



Feldspar, formula of, 293 
Finishing cohesive gold filling, 137 

abrasives in, 138 

burnishing in, 137 ' 

gingival excess in, 137 

knife, in, 138 

strips, in, 138 
Floss silk, waxed, use of, 176, 186 



G 



Gingival Angles, class four, 83 
Gingival outline, 

class two, 61, 65 

class three, 73 

class five, 94 
Gold: 

annealing of, 124 

application of, 127 

bridging of, 125 

building of class five, 136 

building of class six, 136 

cement and, 169 

cohesion of, 125 

cohesive physical properties, 123 

condensation, secondary, 137 

condensing of, 127 

covering of pulpal wall, with, 131 

hand pressure in use of, 127 

last portions of, class two, 133 

layers of, 135 

objectionable qualities, of, 123 

order of stepping, 129 
buccal cavities, 129 
class two, 130 
irregular outline, 129 
occlusal cavities, 129 



INDEX 



329 



Gold— Cont 'd 

platinum and, 170 
preparation of, 126 
specillc gravity of, 125 
starting a filling, 

class one, 129 

class two, 129 

class three, 133 

class four, 135 
tin and, 169 
use of, in class five, 95 
welding of, 123 
Gum massage, 185 
Gutta-percha, 164 
base plate, 164 
canal points of, 165 
filling root canals with, 164 
filling with, 164 
preparation of filling, 164 
separation with, 165 
temporary stopping of, 165 



H 

Hand pressure, cohesive gold, 12 S 
Health of patient, 207 
Hydrogen dioxide, 185 
Hyperemia : 

active, 177, 206 

passive, 178 

stages of, 206 
Hypersensitive dentine, defined, 
195 

caustic potassa in, 200 

chloroform in, 202 

cold air in, 199 

dessication of, 198 

destroying agents in, 199 

electric current in, 199 

formaldehyde in, 200 

moisture, heat and cold in, 199 

nitrous oxide in, 202 

novocain, 201 

oil of cloves in, 201 

phenol in, 200 

potassium bromide in, 202 

rapid breathing in, 203 

sharp instruments in, 203 

silver nitrate in, 200 

somnoforme in, 202 



Hypersensitive dentine — Cont 'd 
treatment of, 195-203 
zinc chloride in, 200 



Incisal abrasion, class six, 97 
Incisal angle: 

class three, filling of, 87 
class four, 78 

class four, direction of, 81 
class four, to assist the, 86 
Incisal edge, porcelain inlay, 304 
Incisal line angle, class three, 75 
Incisal outline : 
class three, 74 
class four, plan one, 87 
class five, 94 
Infected dentine, 29 
Inlays : 

beveling of cavo-surface angles, 

100 
carving the wax, 114 
defined, 98 
finishing the, 122 
gold used, in, 121 
heating the gold, for, 120 
history of, 112 
hole leading to model, 121 
indications for, 98 
investing, pattern of, 119 
line of approach, for, 100 
making pattern, for, 113, 119 
making the cast, of, 120 
materials for, 98 
matrix for, 119 
not indicated, 98 
object of, 112 

occlusal restoration, with, 118 
pin for, 116 

placing spruce wire for, 115 
porcelain, construction of, 306- 
311 
applying of, 309 
etching of, 310 
finishing of, 310 
grinding of, 310 
matrix for, 306 
pushing technic of, 310 
selection of, 308 
toilet of, 310 



330 



INDEX 



Inlays — Cont 'd 

retention form for, 51 

retention temporarily removed, 

51 ' 
retention form of pattern, 115 
saturating the model, 120 
setting, 122 

sponge gold as pattern, 119 
sweating the contour, 118, 119 
temperature of the model, 120 
toilet for, 100 
undercuts, filling of, 113 
wax pattern, for, 113 
Instruments, 17-20 
angles in, 18 
bin-angles in, 18 
bur, 19 
care of, 20 
chisel, 

defined, 18 

edge, 18 

use of, 18 
class name, 17 
contra angles in, 18 
cuts of, 314, 324 
dental engine, use of, 19 
ex^>avatois, 17 
few in sight, 174 
formula names, for, 18 
gingival marginal trimmer, 18 
hatchets, defined, 18 
hoes, defined, 18 
how named, 17 
nomenclature, for, 17-20 
plugger, point serrated, 19, 125, 
126 

amalgam, 143 

rotating the, 126 

size of, 126 
rights and lefts, 17 
sharpening of, 19 
spoon, use of, 18 
sub-class name, 17 
sub-order name, 17 
test for sharpness, 20 
triple -angles in, 18 
Instrumentation, lingual pit, 57 



K 



Labial outline: 

class three, 74 

class four, plan one, rule for, 80 

class four, plan three, 90 
Length of sitting (children), 230 
Ligature, 192 

caution in use of, 192 

cutting ends of, 193 

how made, 192 

knot in, 193 

removal of, 193 

Wedelstaedt tie, 193 
Lime salts in solution, precipita- 
tion of, 181 
Line angles, (see Cavity), 

axio-labial, class three, 76 

axio-lingual, class three, 76 

gingivo-axial, 77 
Linen, 174 
Lingual approach: 

advised, 135 

class three, cohesive gold, 135 

inlay illustrated, 105 
Lingual outline: 

class three, 75 

class four, plan one, 87 

lower incisors, 87 
Local anesthesia: 

anatomy, related to, 277 

cocaine in, 277 

defined, 275 

horizontal injection in, 285 

infiltration in, 283 

intra-alveolar in, 285 

novocain, doses of, 279 

novocain in, 277 

pericemental injection in, 286 

perpendicular injection in, 285 

preparing solution for, 280 

Einger's solution for, 281 

suprarenin, doses of, 280 

suprarenin in, 280 

uses in dentistry, 276 



M 



Kaolin, formula of, 293 



Mallet force: 
alone, 128 
automatic, 128 



INDEX 



331 



Mallet f orce— Cont 'd 

hand, 128 , 

power, 128 

rule of, 128 
Marginal bevel: 

angle of, 45 

defined, 27 

depth, of, 45 

necessity of, 27 
Matrix: 

annealing of, 306 

applying porcelain to, 309 

material, for, 306 

methods of forming, 306 

porcelain inlay, 306 

removal of, amalgam, 144 

removal from porcelain, 310 

taking the spring out of, 308 

thickness of, 306 

torn, 309 

use of, class two, gold, 133 

use of, in silicate filling, 162 

use of, with amalgam, 141 
Mouth mirror, use of, 175 

N 

Novocain: 

sensitive dentine, 201 
tablets, care cf, 281 

Nitrous oxide, 202 



Objects in filling teeth, 29, 96 
Occlusal defects, 48 
Occlusal outline: 

class two, 66 

class five, 94 
Operative technic courses, 313, 322, 

323, 324 
Order of procedure: 

cavity, 29 

for inlays, 99 
Outline form: 

buccal pits, 55 

class one, 48 

class two, 59, 65 

class three, 73 

class five, 303 



Outline form — Cont'd 

curving to the axial, class four, 
86 

defined, 34 

distal superior cuspids, 91 

for silicate, 151 

inlays, 

class one, 101 
class two, 103 
class three, 105 

large class one, 52 

lingual pits, 55 

porcelain inlays, 296 

rule one of, 34 

rule two of, 34 

rule three of, 34 

rule four of, 34 

rule five of7 34 

rule six of, 34 

rule seven of, 34 

rule eight of, 34 

rule nine of, 35 

rule ten of, 35 

step omitted in class two, 59 
Over dessication, 71 
Oxychloride of zinc, 146 
Oxyphosphate of copper, 147 
Oxyphosphate of zinc, 146 

manipulation of, 147 

spatulation of, 147 



Pain, dental: 

alleviations of, 177 

cold, causes, 177 

divisions of, 177 

foreign substances, causes, 178 

patents in, 175 

pericemental diseases, causing, 
179 

symptoms, aggravated, 177 

treatment for, 177, 178, 179 
Passive hyperemia of pulp, 178 
Pins: 

placing for inlay, 116 

soldered to matrix, 116 

Tungston, 116 
Planes of ti tooth: 

bucco-lingual, 28 



332 



INDEX 



Planes of a tooth — Cont 'd 

horizontal, 28 

mesio-distal, 28 
Porcelain: 

advantages of, 294 

basal body, 294 

biscuit fuse, 294 

build of layers, 294 

cavo-surface angle for, 295 

cement line in, 301 

composition of, 293 

contra-indications for, 295 

dental, fused, 293-295 

disadvantages of, 294 

double step in, 302 

enamel body, 294 

tine grinding of, 294 

flux, amount of, 294 

foundation body, 294 

high fusing, 293, 294 

indications for, 295 

lingual approach, class three for, 
300 

low fusing, 293 

methods of fusing, 293 

pigments in, 293 

proximal approach for, 301 

shrinkage in, 294 

size of mass, 24 

spheroiding of, 294 
Potassium bromide, 202 
Preventive dentistry, 180 
Primary decay, location of, class 

three, 72 
Prophylactic treatment, oral, 180 

brushing, technic of, 186 

importance of, ISO 

instructions to patients in, 186 

oral hygiene, children, 229 
Proximal Space, restoration of, 31 
Pulp: 

canals, 

air in, 227 

bent, 226 

putrescent, 219 

small, management of, 225 

chamber, cleaning of, 228 

chief idiosyncrasy of, 204 

devitalization, 
causes for, 211 
agents for, 212 



Pulp : 

devitalization — Cont 'd 
anesthetization for, 212 
arsenic trioxide, for, 215 
bacteria as related to, 211 
care exercised in, 214 
determining the method of, 

212 
high pressure for, 213 
methods of, 212 
technic of, 213 

exposed, class one, 53 

exposure, dangers in, class two, 65 

exposure feared, class one, 52 

infected with bacteria, 206 

involved, class five, 95 

lesions of, 177 

normal, 204 

partially devitalized, 218 

peripheral nerve irritation. 212 

preservers, 209 

protection, 204-210 
gutta percha in, 210 
in class two, 66 
in deep seated cavities, 207 
indications for, 205 
materials used in, 207 

putrescence, 219-224 
animal fats in, 221 
autogenous, symptoms of, 222 
autogenous, treatment of, 222 
classes of, 219 
closed, symptoms of, 222 
closed, treatment of, 222 
complicated, symptoms of, 223 
complicated, treatment of, 223 
defined, 219 

open, symptoms of, 220 
open, treatment of, 220 
treatment of, general, 220 

recuperative powers of, 204 

removal of, 214-218 

canal dressing following, 215 
canal filling following, 215 
discolorations following, 215 
hemorrhage following, 215 
pains following, 215 

sensations are conveyed to, 195 

stimuli, abnormal, 211 

stimuli, normal, 211 

traumatic injuries to, 211 



INDEX 



333 



Pus in apical space, 179 
Putrefaction defined, 219 
Pyorrhea alveolaris, 184 

R 

Eegional anesthesia: 

defined, 287 

gasserian injection in, 288 

infra-orbital injection in, 290 

mental injection in, 290 

palatine injection in, 292 

pterygo-mandibular injection in, 
.288 

spheno-maxillary injection in, 288 

zygomatic injection in, 290 
Bemoval of remaining decay: 

class one, 50 

class two, 66 

class three, 77 

for silicate, 154 

inlays, 99 
Resistance form: 

applied to filling material, 39 

buccal pits, 55 

class one, 49 

class two, 62, 66 

class three, 75 

extension for, defined, 38 

force to provide for in, 38 

for porcelain inlays, 296 

for silicate inlays, 151 

importance of, 38 

inlays, 99 

class one, 101 
class two, 103 
class four, plan one, 106 

involves a consideration of, 38 
Retention angles for inlays, 99 
Retention form: 

acute angles required in, 40 

buccal pits, 56 

class one, 49 

class two, 62, 66 

class three, 75 

class four, 78-81 

class five, 94 

flat seats in, 40 
inlays, 
class one, 102 



Retention form: 

flat seats in — Cont'd 
class two, 103 
class four, plan two, 107 

for porcelain inlays, 296 

for silicate, 153 

little, in enamel, 41 

maximum not required, 40 

maximum required, 40 

step as a portion of, 40 
Ringer's solution, 281 
Rubber dam: 

before applying, 38 

class one, 52 

essential in filling with amalgam, 
141 

for silicate, 154 

gingival side of, 191 

holes, distance between, 190 

holes, location of, 190 

holes, size of, 190 

invented by, 187 

leaks in, 46 

method of applying the, 191 

number of teeth isolated with, 
191, 

objections to use of, 187 

occlusal side of, 191 

placing of, 191 

prevent leakage in, 192 

removal of, 194 

size and shape of, 190 

thickness of, 189 



Secretions, abnormal, oral, 196 
Separation: 

class two cavities, 59 

for amalgam, 142 

gutta-percha for, 165 

immediate, 33 

inlays, class two, 102 

methods of, 32 

preliminary, 33 

soreness resulting from, 33 

mechanical not essential, 176 

use of, class two, gold, 133 
Silex, formula of, 293 
Silicate : 

amalgam, and, 171 



334 



INDEX 



Silicate — Cont 'd 

applied to prosthetic work, 172 
cavity preparation for, 150 
defined, 148 ' 

facing metal fillings with, 1G3 
finishing the filling, 162 
gold, and, 171 
making the filling, 155 
making the mix, 159 
preparing the materials, 158 
proper consistency, 159 
time in mixing, 160 
use of matrix, 162 
Silicatization, defined, 148 
Somnoform, 202 
Sordes, consistency of, 183 
Sordes, removal of, 183, 185 
Stains on the teeth, 183 

green stains, color due to, 183 
injury to teeth, 183 
removal of, 185 
where found, 183 
Step: 

area included, class two, 61 
depth of class four, plan two, 87 
distal superior cuspids, 91 
forming of, 61 
omitted in class two, 51 
technic of cutting, class four, 
plan two, 88 



Teeth: 

compared, 270 
order, 

changes in, 271 
disregarding of, 272 
of eruption, 270 
Tin: 

amalgam and, 168 

as a filling material, 166 

cavity preparation for, 167 

discoloration, amount of, 166 

discoloration, by, 166 

forms of, 167 

gold and, 168, 169 

history of, 166 

in teeth of children, 167 

methods of introduction, 167, 

therapeutic action of, 166 

thermal conductivity of, 166 



Toilet of cavity: 

best accomplished by, 45 

class one, 51 

class two, 67 

defined, 45 

for porcelain inlays, 297, 310 

for silicate, 154 
Tooth: 

brush, use of, 185 

form, restoring of, 32 

picks, 186 

substance, saving of, 32 
Tubuli, contents of, 195 



W 



Wall: 
axial, 

class two, 62 

class three, 77 

defined, 23 

for porcelain, class one, 298 

for porcelain, class three, 299 
buccal, class two, 62 
distal superior cuspid, 91, 92 
freshly cut, 88 
gingival, defined, 23 
gingival, class two, 66 
gingival, class three, 77 
gingival, class three, inlay, 105 
inside, defined, 24 
labial, 77 
lingual, 77 
lingual, axial, 62 
lingual, class two, 92 
occlusal, class five, inlay, 110 
outside, defined, 22 
pulpal, class two, 62 
pulpal, defined, 22 
sub -pulpal, defined, 23 
weakened enamel, 38 
Wide enamel margin, indicated, 46 



Zinc: 

chloride of, 200 
oxychlorate of, 146 
oxyphosphate of, 146 
sulphate of, 147 



